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Advanced EMT
FALL 2020
CANDIDATE REVIEW FORM
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INSTRUCTIONS:
Read and complete Steps 1-3 of the Registration Checklist in the Advanced EMT Information Packet.
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STEP 4: Download this form, complete PART 1: STUDENT INFORMATION, and save the file as a PDF. Email
the following items to the Admissions Office staff for application to the Advanced EMT program:
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Registration Form PDF (Part 1 completed)
Copy of your government-issued photo ID (PDF or JPEG)
Affiliation Letter (if affiliated with NC Fire/Rescue/EMS agency)
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STEP 5: You will be contact regarding your application status. Admitted students will be registered for the
class. Payment is due by the deadline listed in the table below.
EMS-4300-01
(51272)
October 12, 2020 –
February 10, 2021
Rotating Schedule:
Odd Weeks: M/T 8:30am-4:30pm
Even Weeks: W/Th 8:30am-4:30pm
Friday, October 9, 2020
at 12pm
a.
PART 1: STUDENT INFORMATION
FULL NAME (first/middle/last): _______________________________________________________________
STREET ADDRESS: _________________________________________________________________________
CITY/STATE/ZIP: _______________________________________ COUNTY: ____________________
HOME PHONE: ____________________________ CELL PHONE: ___________________________________
EMAIL: ___________________________________________________
AFFILIATION: If affiliated, please check the appropriate box and list the complete name of the organization.
(NOTE: If affiliated, applicant must submit a letter from the department verifying active affiliation and good standing.)
Firefighter (Vol) LE Officer
Firefighter (Paid) EM Personnel
EMS Responder (Vol) Telecommunicator/Dispatch
EMS Responder (Paid) Detention Officer
AGENCY: __________________________________ JOB TITLE: ______________________________
STUDENT SIGNATURE: ______________________________________ DATE: _________________
Your signature on this document indicates that the information included in your registration packet is correct
and that you have read and understood the EMT-Initial program information document.
