Location/Vessel Renewal Form

Please complete this form for each location/vessel that requires renewal or re-activation. This ensures PRAXES has accurate information on-file.

*Fields with an asterisk are required.

Location/Vessel Information

Location/Vessel Name *

Location Satellite or Mobile Phone Number (Ideally a 24/7 Phone Number) *

Max # of people at the location/onboard? (Do not include Guests) *

Are Telemed services required for this location/vessel? *YesNo

Start Date of Telemed Coverage (Choosing an approximate date is fine) *

End Date of Telemed Coverage (Choosing an approximate date is fine) *

Who is the service provider for the satellite phone or mobile phone that will be used at this location/vessel? (Optional)

Location/vessel Photo

Do you have a photo of the vessel/location that you can provide? *YesNo

Upload a Photo of your location or vessel (Optional, but preferred)

Click or drag a file to this area to upload.

Acceptable file formats are: .jpg, .jpeg, .gif, .bmp, .png

Company Information

Company / Organization Name *

Name of company representative / main contact for this location/vessel? (i.e. Manager or Supervisor of this location) *

First

Last

Email of Company Representative *

Phone of Company Representative *

Crew members / employees

Do you have a list of the crew/employees that will be on-site at this location/vessel? *YesNo

Upload an Excel spreadsheet of your Crew Members onboard this vessel/at this location. Ideally provide First Name, Last Name, Sex, Role on Vessel and Date of Birth

Click or drag files to this area to upload. You can upload up to 10 files.

Accepted file formats are: .xlsx, .pdf, .xls, .xlsm, .xlsb, .xltx, .xltm, .xlt, .xml, .xlw, .xlr, .xla, .xlam, .csv, .txt, .xps, .doc, .docx, .eps, .ppt, .pptx, .wpd,

Medical kit

Do you have a medical kit on-site at the location/vessel? *YesNo

Please upload an Excel, Word or PDF copy of your Medical Kit at your location. (Optional but preferred) (copy)

Click or drag files to this area to upload. You can upload up to 10 files.

Acceptable file formats are: .xlsx, .pdf, .xls, .xlsm, .xlsb, .xltx, .xltm, .xlt, .xml, .xlw, .xlr, .xla, .xlam, .csv, .txt, .xps, .doc, .docx, .eps, .ppt, .pptx, .wpd,

Caller Information for Telemed Services

Name of Caller #1. This is the main/primary caller on-site at your location/vessel. *

First

Last

Email of Caller #1 *

Role/Job of Caller #1 (Captain, Medic, Project Manager, Chef, 1st Mate, 2nd Mate, etc.) *

Medical Role of Caller #1 (First Aider, Registered Nurse, Primary Care Paramedic, etc.) *

Is there a 2nd caller that you'd like to add? *YesNo

Name of Caller #2 *

First

Last

Email of Caller #2 *

Role/Job of Caller #2 (Captain, Medic, Project Manager, Chef, 1st Mate, 2nd Mate, etc.) *

Medical Role of Caller #2 (First Aider, Registered Nurse, Primary Care Paramedic, etc.) *

Is there a 3rd caller you'd like to add? *YesNo

Name of Caller #3 *

First

Last

Email of Caller #3 *

Role/Job of Caller #3 (Captain, Medic, Project Manager, Chef, 1st Mate, 2nd Mate, etc.) *

Medical Role of Caller #3 (First Aider, Registered Nurse, Primary Care Paramedic, etc.) *

Is there a 4th caller you'd like to add? *YesNo

Name of Caller #4 *

First

Last

Email of Caller #4 *

Role/Job of Caller #4 (Captain, Medic, Project Manager, Chef, 1st Mate, 2nd Mate, etc.) *

Medical Role of Caller #4 (First Aider, Registered Nurse, Primary Care Paramedic, etc.) *

Special instructions

Are there any special notes that you'd like to tell us about this location/vessel? (Optional)

Terms and Conditions

Terms of Use *

• Check this box to confirm you have read and agree with PRAXES Terms of Use.

View a copy of our Terms on our website here: https://praxes.ca/terms

Submit