North Harris EMSP LogoLone Star College - North Harris
EMS Professions
 
Application for Admission to the Advanced EMS Professions Program
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Applicant Information

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If you do not currently hold an EMT credential, have you successfully completed an initial EMT course? *

Do you hold Texas DSHS or NREMT EMT credentials? *

Have you previously attended intermediate, Advanced EMT, or paramedic training? *

Have you ever been convicted of a felony, Class A, or Class B misdemeanor? *

Have you ever had a professional license or certification revoked, suspended, or subjected to other disciplinary proceedings? *

Emergency Contact Information

Education

High School Graduation or GED *
 Name of SchoolAddressDegreeGraduation Date
High School or GED

Have you ever attended a college or university? *

College #1
 Name of CollegeAddressDegree
College #1
Did you graduate from College #1?
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College #2
 Name of CollegeAddressDegree
College #2
Did you graduate from College #2?
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Have you ever attended a trade school? *

Trade or Professional School
 Name of SchoolAddressDegree
School
Did you graduate from School?
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Certifications
 AgencyCourse DirectorExpiration Date
CPR
EMT
NREMT
EMT-Intermediate/Advanced EMT

Other Certifications
 TypeAgencyCourse DirectorExpiration Date
Other 1
Other 2

Relevant EMS/Medical Employment or Volunteer History

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DISCLAIMER—ELECTRONIC SIGNATURE REQUIRED

Please acknowledge each statement by checking each box. * 

Application Checklist

Please carefully read and acknowledge statements *
Signature * 
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