Curriculum Vitae – For Preceptor (Not Student) – Emergency Medical Services University, LLC

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Student ID

Mandatory! Please enter the correct number to receive credit. EMT student ID’s are usually in this format: 123456FT-01 and are located in your email. If you do not know the number, meet Customer Service in Live Chat or call (800) 728-0209.

Preceptor Name:

Agency:

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone:

SUMMARY OF EMPLOYMENT

Dates Employed

Name of Employer

Location (City/State)

Dates Employed

Name of Employer

Location (City/State)

Dates Employed

Name of Employer

Location (City/State)

Dates Employed

Name of Employer

Location (City/State)

EDUCATION

Dates Attended

Name of School

Major

Degree Received

Dates Attended

Name of School

Major

Degree Received

Dates Attended

Name of School

Major

Degree Received

Dates Attended

Name of School

Major

Degree Received

CERTIFICATIONS/LICENSURE

Date Obtained

Name of Certification/Licensure

Expiration Date

Date Obtained

Name of Certification/Licensure

Expiration Date

Date Obtained

Name of Certification/Licensure

Expiration Date

Date Obtained

Name of Certification/Licensure

Expiration Date

School of Dates

Did the Preceptor Agree or Decline to Answer Education and/or Certirication/Licensure Information?

You must still fill out the preceptor’s contact information above.

Signature

Clear Signature

Date

EMS University

SUMMARY OF EMPLOYMENT

EDUCATION

CERTIFICATIONS/LICENSURE

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