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Medi-Ops: Operator Application
We look forward to reviewing your application! We are a very passionate and dedicated team that works hard to improve the lives of others!
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* Indicates required question
Company Name
*
Your answer
Company Principal Address
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Your answer
Company Mailing Address
*
Your answer
Dispatch/ Operations Phone Number
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Your answer
Hours of Operation
*
Your answer
After Hours Emergency Contact if Applicable
Your answer
Business Development/ Contracting Contact: Name
*
Your answer
Business Development/ Contracting Contact: Phone Number
*
Your answer
Business Development/ Contracting Contact: Email
*
Your answer
Compliance Contact: Name
Your answer
Compliance Contact: Phone Number
Your answer
Compliance Contact: Email
Your answer
Operations/ Dispatch Contact: Name
Your answer
Operations/ Dispatch Contact: Phone
*
Your answer
Operations/ Dispatch Contact: Email
*
Your answer
Operations/ Dispatch Contact: Email
*
Your answer
Please Provide a List of the Cities You Service
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Your answer
Check All Services You Offer
*
Ground Courier
Air Medical Courier
Ground Ambulance Transportation
Stretcher Transportation
Air Ambulance Transportation
Private Air Charter
UAV Services
Other:
Required
Do you understand you will be paid as a contractor not as an employee?
*
Yes
No
Maybe
Do you have valid general and professional liability insurance?
*
Yes
No
Maybe
Other:
Name of Company Representative Completing Form
*
Your answer
Name of Company Representative Completing Form: Phone Number
*
Your answer
Submit
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