Department Questionnaire

Department Name (required)

Location (required)

Contact Name (required)

Contact Email (required)

Contact Phone
OfficeCell

Department Information
Staffing (check all that apply) CareerPart-TimeVolunteer
Shift Type 12-Hour24-Hour

Entry Level Requirements (check all that apply)
Entry Level Position Career FF/EMTPart-Time FF/EMTVolunteer/EMT
National Testing Required YesNo
CPAT Required YesNo

Department Reimbursement Requirements
Required Shifts per Month 1234567
Amount of reimbursement every 6 months $200$300$400$500$600$700
Maximum Reimbursement Payout$2000$2500$3000
List other requirements for reimbursement

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