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PACMAT Expression of Interest Form

To express your interest in becoming a PACMAT member, please complete the form below. 
Contact Details:
1.Full Name
2.Email
3.Phone
4.City
5.Ethnicity
6.Do you have any dietary restrictions?
Next of Kin Details:
7.Name
8.Phone Number
9.Email address
10.Relationship to you
Employment Details:
11.Current Role
12.Current Employer
13.Employer contact details (please include a name and email address of a representative we can contact regarding your release for a deployment)
Professional Specialty Areas:
14.Please list your speciality areas (e.g. surgical, general, medical, paediatrics etc)
Regulatory details
15.Do you have a current practicing certificate/licence?
16.Regulatory Authority
17.Expiry date
Expiry date
18.Annual Practicing Certificate
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19.Do you have current indemnity cover?
20.Indemnity Cover
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21.Any restrictions to your working conditions?
Other Relevant Skills & Experience:
22.Previous emergency management or disaster relief training
23.What training have you received? (eg. CIM, CIMS4, NZMAT/AUSMAT).
24.Previous deployment disaster relief experience? 
(include location, role and length of stay)
Uniform:
25.Normal Polo Shirt / T Shirt Size
26.Normal Scrubs Size
Photos on Deployment:
27.Please confirm your approval to use any photos of you for PMA/PACMAT publications.
Attachments Required:
28.Passport
No file chosen
29.Current Curriculum Vitae
No file chosen
30.Immunisation Record
No file chosen
PMA Member
31.Please indicate availability for standby (2024 - 2025 Pacific Cyclone Season)
32.Do you agree to be a member of PMA? (Please select no if you're already a member) Join here.
Agreement & Confirmation:
33.
•  I have read and understood the PACMAT Code of Conduct
•  I give permission for a criminal vetting be completed
•  I give permission for a Working with Children check be completed
•  I understand that I need to be fully vaccinated
•  I understand that information provided in this registration form may be shared with health professional organisations to enable the advance selection and deployment of suitable personnel for deployment(s)
•  I understand that I will need to attend a predeparture briefing in Auckland prior to the deployment unless specifically notified otherwise.