Tuition Reimbursement Scholarship Application
Rural EMS Education Program
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Legal Name *
Street Address *
City *
State *
Zip Code *
Primary Phone Number *
Secondary Phone Number
Email Address *
County of Residence *
Municipality of Residence *
School District of Residence *
Certification Course Level Enrolled *
EMS Educational Institute Enrolled *
Class Location *
Department of Health Class Number
Class Start Date *
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Class End Date *
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Tuition Amount Paid (Not to include uniforms or other additional costs) *
Who paid your tuition? *
Address for who paid your tuition *
Phone number for who paid your tuition *
Upon submitting this application, Proof of Residency /Driver's License and proof of Tuition Payment is required to be submitted via email to: rcarpenter@emsnp.org
 *
Required
Candidate Affirmation

I certify that the facts contained in this application are true and complete to the best of my knowledge, and I understand that if approved for funding, falsified statements on the application may be grounds for repayment of funds provided.  I authorize investigation of all statements contained herein.  I understand and agree that, I am responsible to pay part or all of the scholarship funds back to Emergency Medical Services of Northeastern Pennsylvania, Inc. if I do not successfully complete the educational program requirements or make an attempt at the psychomotor and cognitive exams for certification.  I am aware that my application will be denied without any follow-up if it is deemed to be incomplete.

Electronic Signature (Using Legal Name)

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Date Signed *
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