Internship Application

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Intern with us!

First Name

Middle Initial

Last Name

Home Address

Email

Phone

Best Time to Call

Driver's License #

Driver's License State

Date Available to Begin Internship

Are you lawfully authorized to work in the United States?

Yes

No

Employment History

Employer 1 (most recent)

Phone

Address

Starting Job Title

Ending Job Title

Immediate Supervisor Name & Title

Why did you leave?

May we contact for reference?

Yes

No

Later

Employer 2

Phone

Address

Starting Job Title

Immediate Supervisor Name & Title

Ending Job Title

Why did you leave?

May we contact for reference?

Yes

No

Later

Employer 3

Phone

Address

Starting Job Title

Immediate Supervisor Name & Title

Ending Job Title

Why did you leave?

May we contact for reference?

Yes

No

Later

Have you ever been fired or asked to resign from a job?

Educational Background

School 1

# of Years Completed

Completed

School 2

# of Years Completed

Completed

# of Years Completed

Completed

School 3

Please select all current certifications/licensures from below

KY 115 Hour FF Cert

KY EMT

KY Paramedic

NREMT

Out of State EMT/Paramedic

What college do you plan to attend during the internship?

References

Name

Phone

Title

Relationship to You

Email

# of Years Known

Name

Phone

Title

Relationship to You

Email

# of Years Known

Name

Phone

Title

Relationship to You

Email

# of Years Known

Background Check Documents

The completion & upload of these documents is required as part of the application process.

Download Documents

Background Check Documents

Upload File

.pdf or .doc file types only

Your Signature

Thank you for submitting your application! We will be in touch soon!

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