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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Address (Street Number & Name)

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* 5. Address (City, State, & Zip Code0

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* 6. Telephone Number

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* 7. Date of Birth

Date

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* 8. Gender

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* 9. What is your race/ethnicity? Check all that apply

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* 10. What language(s) are you fluent in? (select all that apply)

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* 11. Emergency Contact & Relation (Full Name & Contact Number)

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* 12. What is your highest level of education?

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* 13. What is your annual household income?

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* 14. Do you have a bank account? (Stipends are paid by direct deposit)

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* 15. If you answered no to the previous questions, are you willing to get a bank account?

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* 16. How many people live in your household (including yourself)

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* 17. Do you have any criminal convictions, currently on parole/ probation or awaiting trial? (If so, this does not preclude you from participating in the program, we ask so that we know which supportive services you may need as a participant)

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* 18. How did you hear about the Public Safety Communications Dispatcher Test preparation program?

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* 19. Why do you want to participate in the Public Safety Communications Dispatcher test preparation program and how will it help you to achieve your overall career goal?

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* 20. Upload Resume

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 21. Upload High School Diploma or GED

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* 22. By submitting this application, I affirm that I have answered all questions completely and truthfully. I understand that if I am accepted, any false statements, omissions or other misrepresentations made by me on this application may result in my immediate dismissal. Your application will be considered incomplete until all documents have been received. If you have any questions, please contact admin@cityemt.org.
Signature & Date

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