Scholarship Application

Applicant First Name *

Applicant Last Name *

Street Address *

Daytime Phone *

Email Address *

Marital Status *

Number of Dependents *

Education

Employment Information

Current Employer *

Street Address *

City, State, Zip *

Contact Person *

Your Spouse's Employer

Spouse's Position

Other Employment History (previous five years)

List affiliation with EMS organization(s), if applicable

EDUCATIONAL INSTITUTION

What EMS program or school do you plan to attend?

What is the cost for the EMS program you will attend?

At which EMS service do you plan to work upon completion of this EMS program?

APPLICANT’S FINANCIAL STATEMENT

(Use previous year’s tax returns and W2 forms)

Your Annual Gross Income *

Spouse's Annual Gross Income *

Total Household Income *

NARRATIVE

In 1,000 words or less, please describe why you are pursuing this educational scholarship and how it will benefit you. The criteria below will be used in the selection process and should be addressed in your narrative:

Commitment to entering the EMS profession;
Financial need;
Dedication to the community;
Ability to serve as a positive ambassador to the EMS profession

AFFIDAVIT

By submission of this application for a NAEMT Foundation Scholarship, I hereby certify that the information contained herein is true and correct and I grant NAEMT Foundation permission to verify any and all information I have provided. If I receive an NAEMT Foundation scholarship, I commit to seek certification in the state in which I reside or with the NREMT upon completion of this program.

Name of Applicant *

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Foundation Scholarship Application