Camp Pendleton PM Program

1. Personal Information

Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

2. Date of Birth

Date / Time

3. I have a current driver's license which is required to register

YesNo

4. I have a high school diploma or a GED

YesNo

5. I have completed an EMT basic course and hold a current EMT card

Yes, I meet or will meet the above requirementNo

6. I hold a CPR card from the American Heart Association "Healthcare Provider Level"

Yes, I meet or will meet the above requirementNo

7. I have a minimum of 1000 hours of part-time or full-time experience as an EMT prior to the application deadline.

Yes, I meet or will meet the above requirementNo

8. Employment Information

Sponsoring Agency

Contact Name

Contact Phone Number

Contact email

9. Have you attended another Paramedic Program

YesNo

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