Apply to the Training Academy - Emergency Ambulance Services, Inc.

Application for EMS Program

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What program are you applying for?*

Applicant Information

Name*

First Middle Last

Preferred Name (Only One)

Former Last Name(s)

Birth Date*

MM slash DD slash YYYY

Gender*

Female

Male

Social Security Number*

Phone Number*

Email*

Address*

Street Address Address Line 2 City State ZIP Code

Arkansas Drivers License #*

Exp. Date*

MM slash DD slash YYYY

Emergency Contact Information

Name*

First Last

Phone*

Relationship*

Education - High School

High School Type*

Public

Private

Homeschool

Name of High School Attended*

Location of High School Attended*

City State / Province / Region

Did you graduate?*

Yes

Graduation Date

MM slash DD slash YYYY

Do you have a GED?*

Yes

Date of Completion

MM slash DD slash YYYY

In what state did you receive your GED?

State

Education - College

Have you ever taken college courses or attended any colleges or universities?*

Yes

Name of College/University

City and State

Attended From (MM/YY)

Attended Until (MM/YY)

Name of College/University

City and State

Attended From (MM/YY)

Attended Until (MM/YY)

Name of College/University

City and State

Attended From (MM/YY)

Attended Until (MM/YY)

Are you at least 18 years of age or older?*

Yes

Have you ever been adjudicated mentally incompetent by a court of law?*

Yes

Field staff must be able to lift at least 100 lbs. Do you have any disability which would prevent you from lifting 100 lbs?*

Yes

Do you have any certifications?*

Yes

Upload a copy of all relevant certifications

Drop files here or

Accepted file types: jpg, png, pdf, Max. file size: 50 MB.

Do you currently engage in the illegal use or illegal acquisition of controlled substances, alcohol or other habit-forming drugs or chemical substances while on duty as a first responder or EMT?*

Yes

Have you been convicted, in this state or another state, of providing emergency medical services or representing yourself as an EMS provider without a license or certificate, or a similar crime directly related to the profession of EMS?*

Yes

If you are or have been certified or licensed as an EMS provider in this state or another state, is your certificate or license currently on probationary status, or has it been suspended or revoked by the board or the EMS certifying or licensing entity in another state?*

Yes

Ethnic Background

This information is optional and will not be used for discriminatory purposes.

Are you Hispanic or Latino?

Yes

Race (Select one or more)

American Indian or Alaskan Native

Asian

Black or African American

White

Native Hawaiian or Other Pacific Islander

Other

I prefer not to provide this information

Military Status

For purposes of the following questions, a veteran is defined as an individual who (1) has engaged in active duty in the U.S. Armed Forces (Army, Navy, Air Force, Marines, or Coast Guard) or is a National Guard or Reserve enlistee who was called to active duty for other than stat or training purposes, or was a cadet or midshipman at one of the service academies, and (2) was released under a condition other than dishonorable. Also answer “Yes” if these conditions do not apply now but will apply by June 30, 2024. An individual should answer “No” if he/she (1) has never engaged in active duty in the U.S. Armed Forces, (2) is currently an ROTC student or cadet or midshipman at a service academy, (3) is a National Guard or Reserve enlistee activated only for state or training purposes, or (4) was engaged in active duty in the U.S. Armed Forces but released under dishonorable conditions.

Are you currently serving on active duty in the U.S. Armed Forces for purposes other than training?*

Yes

Are you a veteran of the U.S. Armed Forces?*

Yes

Are you a member of the National Guard or the U.S. Armed Forces Reserve?*

Yes

Future Plans

Academic Interests*

Career Interest*

What is the highest degree you intend to earn?*

Please write a brief self-evaluation paragraph describing what you have done prior to applying to the EMT program and your future goals in providing pre-hospital care.*

EASI Application Consent*

I have read and agree to the EASI application consent.

Emergency Ambulance Services, Inc. is committed to continuing affirmative action and equal opportunities of access to employment and education and thus does not discriminate against current or potential students on the basis of race, color, religion, sexual orientation, national origin or ancestry, age, disability, sex, military status or status as a veteran. It is also the intent of the EASI to comply with appropriate federal and state laws, rules and regulations and to give special attention to increasing the participation of minorities, women, persons with a disability, and disabled veterans in all levels of the program. It is also the intent of the EASI to ensure that its environment is free from harass mentor intimidation of any kind.

I understand that I am responsible for submitting complete and accurate information on my application form and in all related application materials. I certify that the information contained in this application form and in all application materials is complete and accurate, and I understand that submission of inaccurate information by me or at my direction may be sufficient cause for terminating my enrollment.

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Comments

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Application for EMS Program

Applicant Information

Emergency Contact Information

Education - High School

Education - College

Ethnic Background

Military Status

Future Plans

Emergency Ambulance Service, Inc.

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