EMT - Basic Course Application

EMT - Basic Course Application

FMDH/Stat Ambulance Service
Name: (as it would appear on your license)

First NameMiddle InitialLast Name
Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email:
example@example.com
Please list ANY professional certifications/licenses that you currently hold:
Highest level of education completed:
Have you ever taken an EMT class before?
Did someone refer you to this class?
If yes, name of person.
I certify that the information included on my application is true and accurate to the best of my knowledge. *
Applicant Signature:
Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Applications are submitted to:

FMDH/STAT Ambulance
Kalu Rogenes-Director of Community Healthcare Operations
621 3^rd Street, South
Glasgow, MT 59230
kalu.rogenes@fmdh.org

*Please note all applicants are subject to a background check if accepted into the EMT- basic course.
Frances Mahon Deaconess Hospital does not discriminate in hiring on the basis of race, color, religion, sex, national origin, age, disability, veteran's status or status in any other group protected by federal, state, or local law.
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