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

Applicant's Financial Information

Use last year's tax returns and W2 forms.

Your Annual Gross Income: *

Your Spouse's Annual Gross Income: *

(Use last year's tax returns and W2 forms.)

Total Household Income: *

EDUCATIONAL INSTITUTION

What EMS program or school do you plan to attend?

Expected date of completion: *

NARRATIVE

In 1,000 words or less, please describe why you are pursuing this educational scholarship and how it will benefit you and your community. Please include answers to the following questions in your response:

What are your professional goals and how do you plan to accomplish these goals?
If you receive this scholarship, how will it positively impact your community?
How do you plan to demonstrate the core values of the EMS profession to your community?

AFFIDAVIT

By submission of this application for an NAEMT Diversity Scholarship, I hereby certify that the information contained herein is true and correct and I grant NAEMT permission to verify any and all information I have provided. If I receive an NAEMT Diversity 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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Diversity Scholarship Application

Diversity Scholarship Application

Diversity Scholarship Application

Education

Employment Information

Applicant's Financial Information

EDUCATIONAL INSTITUTION

NARRATIVE

AFFIDAVIT