Inventory Order Request Form

Legal Name on Passport*

Personal Email*

Phone*

Please Check All Achieved Levels of Care (select more than one if applicable)*

Occupational First Aid Level 3 (OFAIII)
Emergency Medical Responder (EMR)
Primary Care Paramedic (PCP)
Advanced Care Paramedic (APC)
Critical Care Paramedic (CCP)
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Other

Occupational First Aid Level 3 (OFAIII) Ticket Upload*

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 100 MB, Max. files: 5.

Please provide proof of OFAIII course completion. Acceptable formats include a screenshot, PDF or legible photograph.

EMALB License Upload*

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 100 MB, Max. files: 5.

Please provide proof of EMALB License. Acceptable formats include a screenshot, PDF or legible photograph.

Registered Nurse (RN) or Licensed Practical Nurse (LPN) License Upload*

Please provide proof of RN or LPN License. Acceptable formats include a screenshot, PDF or legible photograph.

Drop files here or

Accepted file types: jpg, pdf, png, Max. file size: 100 MB, Max. files: 5.

Do You Have Professional Liability Insurance?*

Yes
No

Professional Liability Insurance Upload*

Drop files here or

Max. file size: 100 MB, Max. files: 5.

Please provide proof of your professional liability insurance. Acceptable formats include a screenshot, PDF or legible photograph.

Do You Have A Valid Drivers License?*

Yes
No

Valid Drivers License Upload*

Please provide proof of your valid drivers license. Include both the front and back of drivers license. Acceptable formats include a screenshot, PDF or legible photograph.

Drop files here or

Max. file size: 100 MB, Max. files: 5.

Cover Letter Upload*

Max. file size: 100 MB.

Resume Upload*

Max. file size: 100 MB.

Were you referred by another RCS Team Member?*

Yes
No

Who referred you?*

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