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F-M Ambulance Paramedic Program Application
If you have any questions you may call Ron at F-M Ambulance's Education Department at (701) 364-1754, or send an email to ron.lawler@fmambulance.com.
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Personal Information
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| Full Name: * | |
| Address Line 1: * | |
| Address Line 2: | |
| City: * | |
| State: * | |
| Zip Code: * | |
| Cell number (with area code): * | |
| Alternate Phone number (with area code): * | |
| Email: * | |
| Are you at least 18 years of age? * | Yes No |
| Social Security number | |
General Information
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| Are you applying for the day program or the night program? * | Day Night |
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| I have read and understand the technical standards of the program (provided at www.fmambulance.com/paramedicts) and agree that I am able to meet these standards.
* | Yes No |
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| Is there any information you feel the Admission Committee should be aware of? | |
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| The Program requires that participants practice certain skills on each other. These skills include assessments, back-boarding, cervical collars, IVs, blood draws, oxygen masks/cannulae, cot lifting, stair chairs, splints, bandaging, etc. Are you willing to allow other students to practice in this way? * | Yes No |
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| How did you hear about the F-M Ambulance Service/North Dakota State College of Science Paramedic Program? * | |
Education and Training
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| What level of certification/licensure do you hold? * | |
| Are you certified by the National Registry of EMTs? * | |
| List states that you are currently licensed in (or put none): * | |
| Have you ever lost or had a health care license suspended? * | Yes No |
| If you answered yes, what were the circumstances that led to this suspension or loss? | |
| What is the highest grade you've completed? * | |
| Name of university/degree-awarding institution | |
| Course of study | |
| Degree, certificate, or occupational license awarded | |
Application Submission
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| By checking this box, you agree that the information on this application is accurate and complete. You understand that any omission or inaccurate information may lead to your disqualification from consideration or your termination from the paramedic program. * | I agree |