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El Camino College FIRE ACADEMY APPLICATION FORM AND CHECKLIST NAME First M. I. Last MAILING ADDRESS Number Street Apt. No* City State Zip PHONE Work DRIVER S LICENSE NUMBER ECC I. D. NUMBER or SS NUMBER Home EMAIL ADDRESS Revised 01/09/14 EMPLOYMENT INFORMATION DATES ATTENDED EMPLOYER YOUR POSITION Company Duties Telephone To Title City State From REASON FOR LEAVING Approx Hrs/Week CHECK LIST Official College Transcripts showing completion of 3 units of Fire and Emergency 1 with a grade of C or better. Possession of a valid EMT license or National Registry Card a photocopy of the license or card must accompany the application form. THIS IS IN ADDITION TO THE 3 UNITS OF FIRE AND EMERGENCY TECHNOLOGY 1. An original signed physician s statement. A photocopy of a valid California Driver s License Class C Proof that you have passed a BIDDLE or CPAT test. Completed applications and supporting documents must be submitted to the Industry and Technology Division Office Technical Arts Building Room TA 102. Any missing items will be cause for ineligibility. Please go our website www. elcamino. edu and click on Fire Academy for further information*. No* City State Zip PHONE Work DRIVER S LICENSE NUMBER ECC I. D. NUMBER or SS NUMBER Home EMAIL ADDRESS Revised 01/09/14 EMPLOYMENT INFORMATION DATES ATTENDED EMPLOYER YOUR POSITION Company Duties Telephone To Title City State From REASON FOR LEAVING Approx Hrs/Week CHECK LIST Official College Transcripts showing completion of 3 units of Fire and Emergency 1 with a grade of C or better. Possession of a valid EMT license or National Registry Card a photocopy of the license or card must accompany the application form. Possession of a valid EMT license or National Registry Card a photocopy of the license or card must accompany the application form. THIS IS IN ADDITION TO THE 3 UNITS OF FIRE AND EMERGENCY TECHNOLOGY 1. An original signed physician s statement. THIS IS IN ADDITION TO THE 3 UNITS OF FIRE AND EMERGENCY TECHNOLOGY 1. An original signed physician s statement. A photocopy of a valid California Driver s License Class C Proof that you have passed a BIDDLE or CPAT test. A photocopy of a valid California Driver s License Class C Proof that you have passed a BIDDLE or CPAT test. Completed applications and supporting documents must be submitted to the Industry and Technology Division Office Technical Arts Building Room TA 102. Completed applications and supporting documents must be submitted to the Industry and Technology Division Office Technical Arts Building Room TA 102. Any missing items will be cause for ineligibility. Please go our website www. elcamino. edu and click on Fire Academy for further information*. No* City State Zip PHONE Work DRIVER S LICENSE NUMBER ECC I. D. NUMBER or SS NUMBER Home EMAIL ADDRESS Revised 01/09/14 EMPLOYMENT INFORMATION DATES ATTENDED EMPLOYER YOUR POSITION Company Duties Telephone To Title City State From REASON FOR LEAVING Approx Hrs/Week CHECK LIST Official College Transcripts showing completion of 3 units of Fire and Emergency 1 with a grade of C or better. Possession of a valid EMT license or National Registry Card a photocopy of the license or card must accompany the application form. THIS IS IN ADDITION TO THE 3 UNITS OF FIRE AND EMERGENCY TECHNOLOGY 1. An original signed physician s statement.

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