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UW Hospital and Clinics Emergency Education Center
Initial Paramedic Program Application
***This application must be completed and submitted in its
entirety by June 1, 2020***
1. Demographics:
Full Name:
____________________________________________________________________Last
First MI
Home Address:
_________________________________________________________________
City: _____________________________ State: ___________ Zip:
________________________
Phone:
________________________________________________________________________
E-mail Address:
________________________________________________________________
2. Are you licensed in the state of WI as an EMT? □ YES □ NOIf
you answered “NO” to the above question, in which state(s) are you
licensed?
______________________________________________________________________________
Years of Experience as an EMT:
___________________________________________________
3. A letter of recommendation is required with this application.
Please fill in the belowinformation of the person responsible for
your Letter of Recommendation. This letter maybe from your service
director or medical director:
Full Name:
____________________________________________________________________Last
First MI
How do you know this reference?
__________________________________________________
Phone: _______________________ E-mail:
__________________________________________
4. Current Employment Information:
Employer: ________________________________________ Phone:
_______________________
Address:
______________________________________________________________________
City: _____________________________ State: ___________ Zip:
________________________
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Employer: ________________________________________ Phone:
_______________________
Address:
______________________________________________________________________
City: _____________________________ State: ___________ Zip:
________________________
5. Submit a copy of your: Click here to select and upload your
forms a. AHA BLS cardb. Resume/ CVc. Wisconsin EMT License
Please rank your top 3 options out of the following available
dates and times for the written test (1 is your most preferred
date/time, then your second and third choices). You will be
contacted with confirmation once your application has been
processed.
________ Friday, June 12 at 8:00 am ________ Friday, June 12 at
1:00 pm
________ Monday, June 15 at 8:00 am ________ Monday, June 15 at
1:00 pm
________ Friday, June 19 at 8:00 am ________ Friday, June 19 at
1:00 pm
________ Thursday, June 25 at 8:00 am ________ Thursday, June 25
at 1:00 pm
If you have any questions, please contact one of the
following:
Xandra Lehmann, BSN, RN, CEN EEC Manager
[email protected]
Debi Dahl, BS, NRP Sr. EMS Instructor, Program Director
[email protected]
Once your application is complete and all required documents are
attached, please click the "Submit" button below.
mailto:[email protected]:[email protected]
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Form userFile attachment on: 2020/03/06 15:56:20
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Debra L. Dahl March 14, 2019501 Pheasant TrailDeerfield, WI
53531
Dear Debra:
Congratulations on renewal of your National EMS Certification
for the next 2 year cycle. We recognize thecontribution you have
made toward the validation of your continued cognitive, psychomotor
and fieldcompetency as an EMS professional. NREMT certification
signifies to the public and your peers that you havegone through a
rigorous testing process and maintained those standards through
recertification. You should beproud of maintaining your NREMT
certification as this demonstrates your dedication to the EMS
profession aswell as your duty to protect the public and our
nation.
Your current National EMS Certification will expire on the date
printed on the certification card below. Be sure tovisit
www.NREMT.org for information on the recertification process, as
maintenance of your National EMSCertification is a personal
responsibility. As long as your National EMS Certification remains
valid, theappropriate post-nominal notation after your name for
Paramedic is NRP.
Please keep your on-line NREMT account up-to-date (email
address/mailing address/EMS agency affiliation) sothat you don’t
miss any important future communications. You can also track and
submit your continuingeducation hours through your on-line NREMT
account for future recertification. NREMT merchandise
(decals,embroidered emblems, certificate frames, etc.) may also be
purchased through your on-line NREMT account atwww.NREMT.org.
I wish you a long, safe tenure in your EMS career and extend a
sincere “Thank You” for supporting the missionof the National
Registry of EMTs.
Sincerely,
William SeifarthExecutive Director
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Debra L. Dahl
M0974229 03/31/2021 Paramedic
Executive Director
Form userFile attachment on: 2020/03/06 15:56:45
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Form userFile attachment on: 2020/03/06 16:01:15
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Effective Date Expiration Date
ALS Course Coordinator
This verifies that
has successfully completed the National PEPP course and Course
Coordinator orientation in accordance with AAP
curriculum.
ALS Course Coordinator
PEPP ID Number:
PEPP Course Level: q ALS q BLS
This does not guarantee any future performance or suggest any
form of licensure. The PEPP Course Coordinator verification is
valid for two years.
© 2014 American Academy of Pediatrics
ALS Course Coordinator
This verifies that
has successfully completed the National PEPP course and Course
Coordinator orientation in accordance with AAP curriculum.
This does not guarantee any future performance or suggest any
form of licensure. The PEPP Course Coordinator verification is
valid for two years.
Cut along the dotted line at the bottom of the certificate and
along the dotted lines around the course completion card. Fold the
card in half.
Effective Date Expiration Date
PEPP ID NumberApproved for: q ALS q BLS
January 17, 2007 January 17, 2021
January 17, 2007 January 17, 2021
Debi Dahl
Debi Dahl
6064445
6064445
Form userFile attachment on: 2020/03/06 16:01:25
Home Address: City: State: Zip: If you answered NO to the above
question in which states are you licensed: Years of Experience as
an EMT: How do you know this reference: Applicant Full Name:
Applicant Phone: Applicant Email Address: Reference Full Name:
Reference Phone: Reference Email: Upload: Employer Phone 1:
Employer 1: Employer Address 1: Employer City 1: Employer State 1:
Employer Zip 1: Employer 2: Employer Phone 2: Employer Address 2:
Employer City 2: Employer State 2: Employer Zip 2: Test Option 1: [
]Test Option 2: [ ]Test Option 3: [ ]Test Option 5: [ ]Test Option
4: [ ]Test Option 6: [ ]Test Option 8: [ ]Test Option 7: [ ]Submit:
WI Licensure: Off
