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EMS Background Questionnaire

Complete and include with your application packet.

Applicant name

Date

Answer the following questions. If you answer “Yes,” please provide an explanation on the lines provided (attach additional pages if needed).

Have you ever been convicted of a felony or misdemeanor?
Yes No
Have you ever been placed on probation?
Yes No
Have you ever had disciplinary action taken against a professional license or certification?
Yes No
Are there any circumstances that may prevent you from completing clinical requirements?
Yes No

Applicant signature

Date

PROGRAMS

VISIT

APPLY

The Blinn College District is accredited by the Southern Association of Colleges and Schools Commission on Colleges (SACSCOC) to award associate degrees. The Blinn College District also may offer credentials such as certificates and diplomas at approved degree levels. Questions about the accreditation of the Blinn College District may be directed in writing to the Southern Association of Colleges and Schools Commission on Colleges at 1866 Southern Lane, Decatur, GA 30033-4097, by calling (404) 679-4500, or by using information available on SACSCOC's website (www.sacscoc.org).

The Blinn College District does not discriminate on the basis of race, color, national origin, sex, or disability. For information regarding Title IX, ADA, Section 504, and other anti-discrimination coordinators, see the Student Title IX page.

EMS Background Questionnaire Employment History and Emergency Contact Student Application Blinn College EMS Paramedic Program Application Recommendation Form Program Application Checklist Blinn College EMS Program Physical Form