TEST PURPOSES

Which Start Date are you applying for?*

If you don’t see the program you are looking for listed in the drop-down menu that program is full.

If you have any questions please call Makayla, our Student Services Coordinator, at 508-510-3666 ext. 3.

Second Choice Class Option (OPTIONAL)

Waitlist (OPTIONAL)

Personal Information:

Name*

First Last

Previous Last Name (if applicable)

Social Security Number*

Gender*

Male

Female

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Main Phone*

Email*

Date of Birth*

Why do you want to join our EMT Program?*

Employment History:

Employer*

Employer Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employer Phone

Are you currently serving or have you ever served in the Armed Forces?*

Yes

Education and Experience:

What is your highest level of education?*

Name of High School/ GED Facility*

High School/ GED Graduation Date*

Emergency Contact:

Emergency Contact Name*

First Last

Emergency Contact Phone*

Drivers License:

Drivers Licence Number*

Driver's License State*

Drivers License Expiration Date*

Please upload a copy of your current Drivers License.*

Accepted file types: jpg, jpeg, pdf, Max. file size: 10 MB.

Health Insurance*

Physical Conditions or Limitations:

Do you have any physical limitations that would prevent you from performing tasks invoived in the EMT Program?*

Yes

Please explain physical limitation:

Have you ever been convicted of a felony or misdemeanor offense, in any state, including entering a plea of no contest, which resulted in imprisionment or probation?*

Yes

If you answer yes to the question above please provide a brief explanation below. If you answered no please type in N/A to the box below.*

Affirmation Statement:

I certify that the above information and answers are true, complete, and correct. I understand that any omission of/or misrepresentation of facts are cause for rejection of application and removal from the eligibility list for enrollment in the EMT program. I hereby authorize the National Medical Education & Training Center Administrator to investigate all statements contained here in.*

Yes

E-signature (Check "yes" above and type your full name in box below.)*

E-signature (Check "yes" above and select today's date below.)*

Application Fee:

To finalize your application you must submit the $50, non-refundable, application fee. Upon receipt of your application, you will be sent a PayPal invoice from brad@nmetc.com. Once we receive your application fee, your application will be place under review. You will be contacted within 10 to 14 days once you application has been processed. Next you will be notified regarding your acceptance into the EMT Program via email. Please note that submitting an application does not guarantee acceptance into any program(s). Once you have completed the form, click the “Submit Form” button at the bottom of the page.

Acceptance Letters:

* All students who are accepted into the EMT Program will received a notification via email.

Application Fee Value

Price:

Payment

Submit & Pay Now

Submit & Pay Later

Payment Method

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EMT Application Form (TEST PURPOSES)

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