Personal Information & Owned Equipment Form

Your Full Name

Cell Phone Number

Gender GenderFemaleMale

Email Address

Address

Address 2

City

State

Zip Code

Additional Cities/Zips you can service

What Paramed Companies are you Credentialed with now?

Additional Notes or Questions

Do you own an EKG Machine? Do you own an EKG Machine? Yes No

Internet Access Internet Access Yes No

Do you own a Scanner? Do you own a Scanner? Yes No

Do you have a Fed-Ex Account for Blood Pikcup? Do you have a Fed-Ex Account for Blood Pikcup? Yes No

Do you own a Centrifuge? Do you own a Centrifuge? Yes No

I have 2+ Years Experience as a Paramedical Examiner and will provide records of employment. I have 2+ Years Experience as a Paramedical Examiner and will provide records of employment. Yes No

You will be required to update the website with the status of my cases, as well as when called and when scheduled. You will be required to update the website with the status of my cases, as well as when called and when scheduled. I Agree

All completed paperwork will be scanned and uploaded to the website. All completed paperwork will be scanned and uploaded to the website. I Agree