Paramedic Intern Program Application
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indicates required fields
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Last Name:
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First Name:
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Middle Initial:
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Phone#:
Email:
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Street Address:
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City:
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State:
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Zip:
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CPR:
Yes
No
CPR Expires:
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CEVO/Evoc:
Yes
No
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Level of Licensure:
None
First Responder
EMT-Basic
EMT-IV Technician
EMT-Intermediate
EMT-Paramedic
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Wisconsin License:
Yes
No
Wisconsin License #:
National Registry:
Yes
No
NREMT #:
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ICS 100:
Yes
No
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NIMS 700:
Yes
No
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Why do you want to be a DGEMS Intern?:
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How did you hear about the Intern Program?: