MOBILE MEDICAL CORP.
Government Response Services (GRS)
Expeditionary Medical Response Team

Upon completing this data and reviewing your certifications, you will be contacted for consideration and availability for current and upcoming State and Federal programs.

EMRT positions: EMT-P, EMT, RN, Collaborating Physician (MD/DO), NP, PA, Pharmacist

*If a current team member referred you, please list their name in the section that requests it so that we may contact them for reference.

*MMC Personnel on a current contract may apply for future deployments but must no longer be on a contract to be eligible for deployment.

Todays Date

mm/dd/yyyy

First Name

Last Name

Phone Number

City

State

Zip Code

Do you currently work on an MMC project?

If MMC Staff, list current project and TM:

Have you worked with MMC in the past?

If MMC Team member recommended, list POC:

LinkedIn link (if you have one):

Closest Departure Airport

Postsecondary Education

Primary Medical Specialty

Current certification

Primary Medical License number

EMS ID (12 Digit):

https://www.nremt.org/verify-credentials

Nursing: https://www.nursys.com/LQC/LQCTerms.aspx

NPI: https://npiregistry.cms.hhs.gov/search

Years in Profession

Advanced Medical Training Highlights

If applicable, list ones that are not listed above

Are you a Veteran?

Yes

Branch

If applicable

High Threat, Disaster Response, or Combat Area?

Have you been deployed to a High Threat, Disaster Response, or Combat area previously?

Deployment Host

If applicable

Mobile, Transport, or Remote-Site Medical Projects

Have you worked on Mobile, Transport, or Remote-Site medical projects Previously?

Please Upload Your Resume/CV and ALL Associated Certifications Here:

Drop your files here

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MOBILE MEDICAL CORP.Government Response Services (GRS)Expeditionary Medical Response Team

MOBILE MEDICAL CORP.
Government Response Services (GRS)
Expeditionary Medical Response Team