Landon State Office Building
900 SW Jackson Street, Room 1031
Topeka, KS 66612-1228
Board of
Emergency Medical Services
phone: 785-296-7296
fax: 785-296-6212
www.ksbems.org
Dr. Joel E Hornung, Chair
Joseph House, Executive Director
Laura Kelly
, Governor .
Education Incentive Grant Program
Memorandum of Agreement
Student Form Paramedic
This Memorandum of Agreement (MOA) is between KBEMS,
(Licensed Ambulance Service)
and
(Name of Student- Print)
, SSN# .
(Your social security number is required pursuant to 42 USCS §666(a)(13), KSA74-139 and KSA74-148, and may be used for
child support enforcement purposes or provided to the Kansas Director of Taxation, upon request.)
I
(Name of Student-Print)
agree to work for the above named ambulance service for
a minimum of 24 consecutive months as a: Paramedic
I agree to work a minimum of 20 hours per month for 24 consecutive months of service as required by
the sponsoring organization/requesting agency. The sponsoring organization/requesting agency shall schedule
me for a minimum of 20 hours per month.
I further agree that:
Should I fail to meet this two year of service obligation, or if I drop out of the course
prior to completion, I will within 14 days repay KBEMS 100% of the grant monies
awarded to me through the Licensed Ambulance Service. *
Should I academically fail the course, or if I am denied to take the certification exam, I will
within 14 days repay KBEMS 50% of the grant monies awarded to me through the
Licensed Ambulance Service.
Should I be unsuccessful in gaining certification after all allowed attempts at the
certification exam, I will not be asked to repay KBEMS any of the grant monies awarded to
me through the Licensed Ambulance Service.
The grant monies awarded to me will be utilized as specified in the grant criteria.
Should I not make all allowed attempts at certification exam, I will within 14 days repay
KBEMS 100% of the grant monies awarded to me through the Licensed Ambulance Service.
* The required 24 months of service obligation may be transferable to another eligible service in the state
with the approval of the service directors and operators.
(Ambulance Service Director) (Date)
(Signature of Student)
(Date)
(
KBEMS)
(Date)
Rev. 12/18
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