Contact Information Name: * Address: * City: * State: * Zip: * Phone: * Email: * Your Occupation: (other than student) Estimated Annual Household Income: * Marital Status: * Single Married Number of dependents: Employment Status: * Employed full-time Employed part-time Student Status: * College student full-time College student part-time Educational History High School Name/GED: * Graduation year: * College Name: Graduation year (or expected): Paramedic Training Program Information Program Name: * Program's Address: Street Address, City, State and Zip Program Lead Instructor Name: Lead Instructor's Phone: Lead Instructor's Email: Background Please answer the following questions: Have you ever been convicted of a felony or misdemeanor? Yes No Have you ever been convicted of driving under the influence? Yes No Have your driving privileges ever been revoked? Yes No Have you ever been disciplined or discharged for theft or dishonesty? Yes No May we contact your references? Yes No References Please include three letters of recommendation. The letters should address your commitment to Paramedic Training, your EMS experience, qualifications, community service, and other qualifications that would merit an award of scholarship. May we contact your references? * Yes No   Reference #1 Name: * Address * Street Address, City, State and Zip Phone: * E-mail: * Reference Letter: *   Reference #2 Name: * Address * Street Address, City, State and Zip Phone: * E-mail: * Reference Letter: *   Reference #3 Name: * Address * Street Address, City, State and Zip Phone: * E-mail: * Reference Letter: * About you 1. Why are you interested in becoming a paramedic? * 2. When you complete paramedic training, where do you plan to work as a paramedic? * 3. In what ways have you provided service to your country and community? * 4. Why do you believe you should be considered for a scholarship from MARCER? * To the best of my ability, I attest the above information to be accurate and true. * I agree. Type this code: *