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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.
Please enable JavaScript in your browser to complete this form.
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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