Presence Saint Francis Hospital
2016 Paramedic Program
ASSESSMENT TESTING APPLICATION
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Presence Saint Francis Hospital
EMS Office
355 Ridge Avenue
Evanston, IL 60202
847.316.6117
EMS Office
Date Received ___________________________
Name
Social Security Number
Last
First
Middle Initial
Residence Address
City
Home Phone Number
State
Zip
Cell:
(Required)
E-mail Address
(Required)
EMS BACKGROUND
Location of EMT School
Completion Date
IDPH EMT-B ID Number
Expiration Date
$50 Application Fee
EMT-B License
TEST DATE / TIME:
Friday, November 6, 2015
8 a.m.
12:30 p.m.
Saturday, November 7, 2015
8 a.m.
12 30 p.m.
This application is due in the EMS Office at Presence Saint Francis Hospital by 3 p.m.,
Friday, Oct. 30, 2015, along with $50 (cash only) application fee.
Student Signature
Date