EMT Application Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Birth Date * MM DD YYYY Social Security Number * Home Phone * (###) ### #### Cell Phone (###) ### #### DRIVERS LICENSE #: * State Issued * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming EXPIRATION DATE * MM DD YYYY High School Diploma / GED Completion Date * Address Please list address of places you have lived in the past five (5) years (do not include current address): Address 1 Address 2 City State/Province Zip/Postal Code Country Address Please list address of places you have lived in the past five (5) years (do not include current address): Address 1 Address 2 City State/Province Zip/Postal Code Country Address Address 1 Address 2 City State/Province Zip/Postal Code Country Please Answer the Following Questions Notice: All questions on this application must be answered. Failure to respond to these questions will result in the application being returned as incomplete. If you answer ‘Yes’ to any of the questions below you must attach an explanation on a separate sheet including copies of court documents, disciplinary actions, of physician’s statement, if applicable. Have you ever been convicted of a felony, plead guilty to a felony, entered into an Alford plea to a felony, or participated in a diversion program for a felony? Have you ever been convicted of a felony, plead guilty to a felony, entered into an Alford plea to a felony, or participated in a diversion program for a felony? Yes No Have you ever been convicted of a misdemeanor? Yes No Have you ever been convicted of Driving Under the Influence (DUI)? Yes No Have you ever been cited for a moving violation while operating and emergency medical vehicle? Yes No Have you ever had a civil judgment entered against you arising from a situation(s) in which you were delivering or attempting to deliver medical care? Yes No Have you ever been in default on any student loans? Yes No Have you at any time had your certification(s) or registration(s) as a EMR/First Responder, EMT, Advanced-EMT, Paramedic, Registered Nurse, Physician or its equivalent, been restricted, revoked, denied, suspended or expired in the Commonwealth of Kentucky or another state? Yes No Have you at any time had any instructor certification restricted, revoked denied, suspended, or expired? Yes No Are you currently under disciplinary action with KBEMS? Yes No What level of certification do you currently have? * EMT Advance Paramedic American with Disabilities Act (ADA) Notification If you have a physical, mental, or other disability which might entitle you to receive restricted certification or License in education or employment you must supply medical records or documentation thereof to receive reasonable accommodation. KBEMS -I hereby certify that the information provided on this application is complete and true. I understand that knowingly supplying false information on this application is a citation of KRS Chapter 311A and/or 202 KAR 7 and subjects me to the full range of disciplinary action described therein. I further understand that my application can be returned to me incomplete if I failed to provide all information requested on this application. NREMT - I hereby affirm and declare that all the above information on this application is true and correct. - I understand and agree that I may be disqualified from taking the NREMT Examination or seeking NREMT certification and registration or my NREMT certification and registration may be revoked in the event that any of the statements made by me on this application or any information submitted by me are false or if I have failed to provide material information. -I also agree to abide by all policies and procedures of the NREMT. -I understand and agree that: (1) the giving or receiving of aid in an examination as evidenced either by observation or by statistical analysis of incorrect answers of one or more participants in the examination; (2) the unauthorized possession, reproduction, or removal from the testing center of any examination materials, including the nature or content of examination questions or answers, before, during or after examination; (3) the offering of any benefit to an agent of the NREMT in return for any right, privilege, or benefit which is not usually granted by the NREMT which is not usually granted by the NREMT to other similarly situated candidates r persons; and/or (4) the engaging in irregular behavior in connection with the administration of an examination (as defined in the NREMT policies), authorizes the NREMT to bar me from future examinations, terminate my participation in any examination, invalidate the results of my examination, withhold or revoke my scores or certificate, or take other appropriate action. Signature Sign at the station when called in. Date * MM DD YYYY Thank you for applying! Your application has been submitted for review.