Medi-Ops: Operator Application

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We look forward to reviewing your application! We are a very passionate and dedicated team that works hard to improve the lives of others!

Company Name *

Company Principal Address *

Company Mailing Address *

Dispatch/ Operations Phone Number *

Hours of Operation *

After Hours Emergency Contact if Applicable

Business Development/ Contracting Contact: Name *

Business Development/ Contracting Contact: Phone Number *

Business Development/ Contracting Contact: Email *

Compliance Contact: Name

Compliance Contact: Phone Number

Compliance Contact: Email

Operations/ Dispatch Contact: Name

Operations/ Dispatch Contact: Phone *

Operations/ Dispatch Contact: Email *

Please Provide a List of the Cities You Service *

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

Maybe

Do you have valid general and professional liability insurance? *

Yes

Maybe

Other:

Name of Company Representative Completing Form *

Name of Company Representative Completing Form: Phone Number *

Submit

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