» Community Paramedicine Online Application

Name*

First Name Middle Name Last Name

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

High School or GED Program Last Attended*

Name	City	State

High School/GED year graduated*

Have you attended EMCC before?*

Resident of Maine for one year?*

Academic semester you are applying for*

Gender

Optional

Ethnicity

Optional

Race

Optional

Current Employer*

Employer Address*

If student, current major or program of study

Have you ever been removed or excluded from any health care facility due to allegations that you engaged in a form of neglect or other misconduct?*

Yes
No

If yes, please explain for each incident the following (please email supporting documents); Nature of Incident:

Name and contact information for Facility at which the incident occurred:

Your age when the incident occurred:

Further Explanation:

State Licensed in:*

License Number:*

Letter of Support

Drop files here or

Max. file size: 50 MB.

A letter of support from a Medical Director or Service Chief is required of all applicants and is reviewed as an important part of the selection process.

Do you have at least two years of experience in EMS?*

Yes
No

Signature (Please type name)*

By signing your name you confirm all the information reported here is accurate.

Date Signed*

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