To express your interest in becoming a PACMAT member, please complete the form below. 
Contact Details:

Question Title

* 1. Full Name

Question Title

* 2. Email

Question Title

* 3. Phone

Question Title

* 4. City

Question Title

* 5. Ethnicity

Question Title

* 6. Do you have any dietary restrictions?

Next of Kin Details:

Question Title

* 7. Name

Question Title

* 8. Phone Number

Question Title

* 9. Email address

Question Title

* 10. Relationship to you

Employment Details:

Question Title

* 11. Current Role

Question Title

* 12. Current Employer

Question Title

* 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:

Question Title

* 14. Please list your speciality areas (e.g. surgical, general, medical, paediatrics etc)

Regulatory details

Question Title

* 15. Do you have a current practicing certificate/licence?

Question Title

* 16. Regulatory Authority

Question Title

* 17. Expiry date

Date

Question Title

* 18. Annual Practicing Certificate

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

Question Title

* 19. Do you have current indemnity cover?

Question Title

* 20. Indemnity Cover

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

Question Title

* 21. Any restrictions to your working conditions?

Other Relevant Skills & Experience:

Question Title

* 22. Previous emergency management or disaster relief training

Question Title

* 23. What training have you received? (eg. CIM, CIMS4, NZMAT/AUSMAT).

Question Title

* 24. Previous deployment disaster relief experience? 
(include location, role and length of stay)

Uniform:

Question Title

* 25. Normal Polo Shirt / T Shirt Size

Question Title

* 26. Normal Scrubs Size

Photos on Deployment:

Question Title

* 27. Please confirm your approval to use any photos of you for PMA/PACMAT publications.

Attachments Required:

Question Title

* 28. Passport

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

Question Title

* 29. Current Curriculum Vitae

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

Question Title

* 30. International Vaccination Card

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File
PMA Member

Question Title

* 31. Please indicate availability for standby (2022 - 2023 Pacific Cyclone Season)

Question Title

* 32. Do you agree to be a member of PMA? (Please select no if you're already a member) Join here.

Agreement & Confirmation:

Question Title

* 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.

T