Application Information

Male Female

Please list address of places you have lived in the past five (5) years (do not include current address):

Please Answer the Following Questions
Notice: All questions on this application must be answered. Failure to respond to these questions will result in the application
being returned as incomplete. If you answer ‘Yes’ to any of the questions below you must attach an explanation on a separate
sheet including copies of court documents, disciplinary actions, of physician’s statement, if applicable.

Have you ever been convicted of a felony, plead guilty to a felony, entered into an
Alford plea to a felony, or participated in a diversion program for a felony? Yes No

Have you ever been convicted of a misdemeanor? Yes No

Have you ever been convicted of Driving Under the Influence (DUI)? Yes No

Have you ever been cited for a moving violation while operating and emergency
medical vehicle? Yes No

Have you ever had a civil judgment entered against you arising from a situation(s)
in which you were delivering or attempting to deliver medical care? Yes No

Have you ever been in default on any student loans? Yes No

Have you at any time had your certification(s) or registration(s) as a EMR/First
Responder, EMT, Advanced-EMT, Paramedic, Registered Nurse, Physician or its
equivalent, been restricted, revoked, denied, suspended or expired in the
Commonwealth of Kentucky or another state? Yes No

Have you at any time had any instructor certification restricted, revoked denied,
suspended, or expired? Yes No

Are you currently under disciplinary action with KBEMS? Yes No

American with Disabilities Act (ADA) Notification
If you have a physical, mental, or other disability which might entitle you to receive restricted certification or License
in education or employment you must supply medical records or documentation thereof to receive reasonable

Applicant Declaration(s) for KBEMS & NREMT

I hereby certify that the information provided on this application is complete and true. I understand that knowingly
supplying false information on this application is a citation of KRS Chapter 311A and/or 202 KAR 7 and subjects me
to the full range of disciplinary action described therein. I further understand that my application can be returned to
me incomplete if I failed to provide all information requested on this application.

I hereby affirm and declare that all the above information on this application is true and correct. I understand and
agree that I may be disqualified from taking the NREMT Examination or seeking NREMT certification and registration
or my NREMT certification and registration may be revoked in the event that any of the statements made by me on
this application or any information submitted by me are false or if I have failed to provide material information.
I also agree to abide by all policies and procedures of the NREMT.
I understand and agree that: (1) the giving or receiving of aid in an examination as evidenced either by observation
or by statistical analysis of incorrect answers of one or more participants in the examination; (2) the unauthorized
possession, reproduction, or removal from the testing center of any examination materials, including the nature or
content of examination questions or answers, before, during or after examination; (3) the offering of any benefit to
an agent of the NREMT in return for any right, privilege, or benefit which is not usually granted by the NREMT which
is not usually granted by the NREMT to other similarly situated candidates r persons; and/or (4) the engaging in
irregular behavior in connection with the administration of an examination (as defined in the NREMT policies),
authorizes the NREMT to bar me from future examinations, terminate my participation in any examination,
invalidate the results of my examination, withhold or revoke my scores or certificate, or take other appropriate
I hereby authorize the NREMT to release any information including examination scores to my teaching institution,
any state EMS office or other state agency empowered to grant licensure or authorization to practice as an EMS
professional. I further permit the NREMT to release my current status with NREMT (registered or not registered) to
the public.
I hereby release, discharge, covenant not to sue, and hold harmless, the NREMY, its directors, officers, members,
examiners, representatives, agents and any person who supplies information regarding my application from any
actions, suits, claims, demands, or damages arising out of, or in connection with any action taken by any of them
regarding this application, the scoring of any NREMT examination, the failure of the NREMT to certify and/or register
me or the revocation of my registration. It is understood that all decisions as to my eligibility for admission to an
examination and for certification and registration rest solely and exclusively in the NREMT, that its decisions are
final, and my exclusive appeal from any adverse decision is pursuant to the NREMT’s rules and procedures.

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