2017 Paramedic Program Application
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AM/PM Option
What is your name?
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First Name
Last Name
What is your email address?
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What is your cell phone number?
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Area Code
Phone Number
What is your date of birth?
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Please select a month
January
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Year
What is your fire service ID?
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What is your primary fire-rescue affiliation? CAREER = DFRS
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Please Select
DFRS
Bethesda
Bethesda-Chevy Chase
Burtonsville
Cabin John
Chevy Chase
Damascus
Gaithersburg
Germantown
Glen Echo
Hillandale
Hyattstown
Kensington
Laytonsville
Rockville
Sandy Spring
Silver Spring
Takoma Park
Upper Montgomery
Wheaton
Other / Non-MCFRS
List your primary affiliation
What is your rank?
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Please Select
EMS Provider I
EMS Provider II
EMS Provider Master
EMS Provider LT
FF1
FF2
FF3
MFF
LT
CA
Other
Station assignment
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R1
R2
Not assigned to a station
Non-MCFRS
What shift are you on?
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Please Select
A
B
C
D
Volunteer
Non-MCFRS (MSP, USPP, FBI)
For which class are you applying?
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Please Select
A Shift Class
B Shift Class
C Shift Class
Night Class
Have you been a charge EMT for at least one year, or served as charge EMT on at least 150 calls?
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Please Select
Yes
No
Have you ever applied for ALS certification or licensure in Maryland or any other State?
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Please Select
No
Yes
In what state did you apply?
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
When did you apply for ALS certification or licensure?
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Was your request for certification or licensure granted?
Please Select
Yes
No
Please explain why your application for certification or licensure was denied.
Have you had any healthcare certification or license withheld, suspended, revoked, or denied, or, have you surrendered or allowed a license or certificate to expire or lapse as the result of an investigation or disciplinary action?
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Please Select
No
Yes
Please explain why your ALS, BLS, or other medical certification or license was withheld, suspended, revoked, or denied. Be sure to include the level or type of certification, when and by whom the denial was made.
Have you ever been convicted of, or plead guilty to, or pled nolo contendre to any crime other than a minor traffic violation?
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Please Select
No
Yes
Please explain the circumstances of the conviction or plea. Be sure to include when and where the incident happened, and what the outcome was.
Please provide email addresses to 3 references. References must include a County paramedic, your supervisor, and one other person not related to you.
Please separate email addresses with a comma.
CAREER applicants - Please provide your station officer's email. VOLUNTEER applicants - Please provide your chief's email.
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Please upload a picture or scanned image of your current EMT card
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I understand that all of the information I provided in this application is subject to verification. I affirm and declare that all of the information contained in this application is true and correct to the best of my knowledge. I acknowledge that entry of any fraudulent information may be considered sufficient cause for rejection from the application process. By signing my name below, I agree to the terms and conditions listed above.
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