Contact Details:

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* 1. Title

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* 2. Name

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* 3. Alias (Name You’re Known by if Different)

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* 4. Full Name on Passport

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* 5. Email

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* 6. Phone

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* 7. Date of Birth

Next of Kin Details:

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* 8. Name

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* 9. Phone Number

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* 10. Email address

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* 11. Relationship to you

Employment Details:

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* 12. Current Role

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* 13. Current Employer

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* 14. Date started in the role

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* 15. 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:

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

Qualifications:

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* 17. Please list your relevant qualifications (where you studied and the date you graduated). Please include any college memberships/fellowships:

Practicing Certificate Details:

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* 18. Licencing Body & Country

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* 19. Expiry date

Other Relevant Skills & Experience:

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* 20. Please detail any other relevant skills, experience or training which outline your suitability for a PACMAT deployment

Attachments Required:

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* 21. Please attach copies of your CV, your APC and your passport. If you are a medical doctor, please also attach a copy of a recent certificate of professional status (this can be applied for via the NZ Medical Council website).

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Uniform:

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* 22. Normal Polo Shirt / T Shirt Size

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* 23. Normal Scrubs Size

Photos on Deployment:

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* 24. Please confirm your approval to use any photos of you for PMA/PACMAT publications (write yes and your name)

Pre-departure Briefing:

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* 25. Please confirm your understanding that you MUST attend a predeparture briefing in Auckland prior to a deployment, unless specifically notified otherwise)

Before sending this form to confirm your interest in joining a PACMAT deployment, please ensure you have included the following attachments:

·       Current CV (if you need to update your CV, please use the template on the website)

·       Copy of your current APC (all personnel must hold and maintain a current APC)

·       Copy of your current Passport (please note you can only travel if your passport has more than 6 months left prior to expiry.  Any costs related to renewing passports is your responsibility).

·       Current Certificate of Professional Status (Doctors only - available through application from the New Zealand Medical Council)

·       Completed Police check form (can be found on the website)


Should you have any queries, please contact Pasifika Medical Association on 09 250 5791.

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