Emergency Medical Sciences Application

First Name:

Middle Name:

Last Name:

E-mail Address:

Phone:

Last four numbers of your Social Security Number:

Student ID:

Address:

City:

State:

Zip code:

Highest level of education completed:

Have you ever been convicted of a felony?

Yes

No

If "Yes", you have been convicted of a felony, please explain the circumstances around the conviction:

Have you ever had a professional license or certification on probation, suspended, revoked or have any other type of administrative action on a healthcare license, certification or any other professional license or certification in any other professional field?

Yes

No

If you answered yes to the previous question, please explain the circumstances around it:

How did you hear about our EMS program? (check all that apply)

UA-PTC Website

Counselor

Recruiting Event/Job Fair

Radio, Billboard or TV ad

Social Media

Other...

Have you previously attended one of our EMS programs (EMT or Paramedic)? If so, when?

If you previously attended one of our EMS programs (EMT or Paramedic) at UA-PTC did you successfully complete the course?

If you previously attended one of our EMS programs (EMT or Paramedic) but did not obtain licensure? Describe the reason and/or why you left prior to obtaining licensure?

Have you previously attended an EMT class at any other location? If so, please describe all dates of attendance, when and why you left?

Have you previously attended a Paramedic class at any other location? If so, please describe all dates of attendance, when and why you left?

Are you at least 18 years of age?

Yes

No

Do you have a high school diploma or GED?

Yes

No

Are you intending to work as an EMS provider after completing this program?

Yes

No

Do you hold a current Arkansas license?

Yes

No

Lapsed

Please provide your current or lapsed Arkansas license number:

Type N/A if you don't have an Arkansas license.

Please explain any reason why your Arkansas license may have lapsed, or expired:

Type N/A if you don't have an Arkansas license.

Do you hold a current National certification?

Yes

No

Lapsed

Please provide your current or lapsed National certification number:

Type N/A if you don't have a National certification.

Please explain any reason why your National certification may have lapsed, or expired:

Type N/A if you don't have a National certification.

Do you hold a current American Heart BLS Healthcare Provider license?

Yes

No

Lapsed

Please provide your current or lapsed American Heart BLS Healthcare Provider license number:

Type N/A if you don't have an American Heart BLS Healthcare Provider license.

Please explain any reason why your American Heart BLS Healthcare Provider license may have lapsed, or expired:

Type N/A if you don't have an American Heart BLS Healthcare Provider license.

Certification of Information:

I certify that the information provided in this application is true and complete and understand that intentional false statements could lead to program dismissal as a student or rejection as an applicant.