CE: Paramedic Student Application Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email NREMT Certification Number (If you are not NREMT, put N/A)* Iowa Certification Number* IA Certification Number 1. How many years of experience in EMS?* 2. Do you work full time?* Yes No Where do you work?* 3. Are you currently on a fire / rescue department?* Yes No If yes, which department?* 4. Have you attended any Advanced EMS certification (paramedic or AEMT) courses in the past?* Yes No If yes, please write details:5. Are you interested in starting the Paramedic Program January 2024? Yes No Please list 2 personal references:Person #1* First Last Position/company* Phone number:*Email* Person #2* First Last Position/company:* Phone number:*Email*
