Work Verification Form - Paramedic - AASN Option

Arkansas State University – School of Nursing 

 Paramedic – AASN Program Option 

 Employer Documentation of Work Experience 

   

 Student Name: _______________________________________________________

 A-State Student ID#: ________________________________ 

 The applicant MUST provide proof of work experience reflecting current employment as a paramedic. The form MUST be signed by the Human Resource Representative or Supervisor and returned to the School of Nursing by the employer. The form may be returned by postal mail or email from the employer.  If returned by postal mail, then a facility envelope must be used with a signature across the seal. An email submission must be from an employer email address, not a personal email address. Please use the instructions below for submission by postal mail or email. 

 **Note: If documentation of work experience is not submitted properly, the student’s application will be incomplete.** 

   

   My signature below confirms that ___________________________________ has completed over ____________ hours work within the past 

 _________ years at the facility indicated below. 

   

 Name of Institution: ___________________________________________________________________________________ 

 Address: _____________________________________________________ 

 City/State/Zip: __________________________________________________________               Telephone: ______________________________ 

 Signature: ______________________________________________                       Date: __________________________ 

 Title of Person Completing Form: __________________________________________________________________ 

 Mail to: 

 A-State School of Nursing 

 Attention: Paramedic – AASN Admission Committee 

 P.O. Box 910 

 State University, AR 72467 

   

 Email to: 

 cnhp@astate.edu