Apply Now – NZMAT

PERSONAL DETAILS

Please complete all MANDATORY FIELDS (*) to proceed.

This form takes around 20 minutes to complete.
Make sure to fill up all necessary information before submission.

Title *

First Name *

Middle Name(s)

Last Name *

Preferred Name

Gender *

DOB*(month/day/year)

Country of Birth *

Ethnicity *

Attach ID Photo*
(Must meet New Zealand passport photo standards)
Maximum upload file size: 2mb

CONTACT DETAILS

When completing this section, please ensure that you provide the best details to easily contact you.

Contact Details – Phone numbers *

Home

Work

Work Mobile

Personal Mobile

Contact Details – Email Address *

Personal

Alternative Personal

Work

Contact Details – Address *

Number and Street

Suburb

City

Postcode

EMPLOYMENT DETAILS

Please complete all MANDATORY FIELDS (*) to proceed.

Current Position *

Number of years in this Position *

Does your current role have a Clinical Component? *

Current Employment *

Name of Employer *

Has your employer signed the ‘Employer’s Acknowledgement Form’? *

Attach signed Employer’s Acknowledgement Form
Maximum upload file size: 3mb

PROFESSIONAL DETAILS

Please complete all MANDATORY FIELDS (*) to proceed.

Professional Category*

Allied Health

Doctor

Registered Nurse

Nurse Practitioner

Midwife

Public Health

Other

Post Graduate Qualifications

Have you completed any of the following courses: (please input year)

Advanced Life Support in Obstetrics course

Practical Obstetric Multi-Professional Training course (PROMPT)

Advanced Cardiac Life Support course (ACLS)

Advanced Paediatric Life Support course (APLS)

Nurse Vaccinator

Real World Anaesthesia Course (RWAC)

Diploma in Obstetrics

Diploma in Paediatrics

Early Management of Severe Trauma (EMST)

Please list any other relevant courses you have completed:

Please list any AUSMAT courses completed:
NB: Include year undertaken

Attached Professional Documentation
Maximum upload file size: 4mb

Attach current Curriculum Vitae
Maximum upload file size: 3mb

REGULATORY DETAILS

Please complete all MANDATORY FIELDS (*) to proceed.

Current Practicing Certificate / Licence

Nursing Council Registration Number

Midwifery Council Registration Number

Medical Council Registration Number

Medical Sciences Council Registration Number

Pharmacy Council Registration Number

Physiotherapist Board Registration Number

Paramedic Council Registration Number

Other Registration Number

HPI Number

Attach copy of regulatory papers (APC / Licence)
Maximum upload file size: 2mb

Are you a member of a professional body *?

Do you have current Indemnity Cover *?

Do you have any restrictions relating to your working conditions? *

Define restrictions on working conditions

CITIZENSHIP DETAILS

Please complete all MANDATORY FIELDS (*) to proceed.

New Zealand Citizen *

Other citizenship

Are you currently legally able to work in NZ

NZ Passport Number

NZ Passport Expiry Date (month/day/year)

NZ Passport Full Name

NZ Passport Place of Issue

Other Citizenship Passport Number

Other Citizenship Passport Expiry Date(month/day/year)

Other Citizenship Passport Full Name

Other Citizenship Passport Place of Issue

Do you have a visa associated with your passport?

What is the visa for?

Expiry Date of Visa (month/day/year)

Attach copy of passport photo page(s) and visa page(s) *
Maximum upload file size: 3mb

DRIVER LICENCE DETAILS

Please complete all MANDATORY FIELDS (*) to proceed.

Current NZ Driver Licence *

Driver Licence Number

Driver Licence Type

Driver License Expiry Date (month/day/year)

Attach copy of drivers licence (front and back)
Maximum upload file size: 3mb

MEDICAL / VACCINATION DETAILS

Please complete all MANDATORY FIELDS (*) to proceed.

Level of Fitness *
Please state weekly activity

Mandatory Vaccinations

COVID-19

COVID-19 Booster

Chickenpox

Haemophilus Influenza Type-B

Hepatitis A

Hepatitis B

Influenza

Measles / Mumps / Rubella

Meningitis ACWY

Polio

Pneumococcal

Tetanus / Diphtheria / Pertussis (Boostrix)

Typhoid

Optional Vaccinations

Cholera

Japanese Encephalitis

Rabies

Attach copy of vaccination passport / documentation
Maximum upload file size: 5mb

Do you have a history of any transmissible major viral infections?

Have you have ever had Dengue Fever?

If yes, do you consent to a review by a clinical infectious diseases’ clinician regarding your status?

Do you currently have any medical conditions that could affect your ability to function effectively in an austere environment?*

If yes – please specify

Do you have any medical conditions NZMAT should be aware of?*

i.e. asthma, diabetes (insulin dependent), CPAP, pacemaker

If yes – please specify

Do you have any restrictions placed on area of practice due to any medical conditions?

If yes, do you consent to share those restrictions with NZMAT administration?

Do you have any allergies? *

If yes – please give details

Do you have any phobia? *

If yes – please give details *

If required, do you consent to undergo a self-funded medical assessment by a General Practitioner where the results will be shared with NZMAT administration?

Do you have any dietary limitations?

If yes – please give details *

NB: Please note some dietary limitations cannot be accommodated on deployment i.e. personnel are issued with standard ration packs when required or country deployed into cannot accommodate dietary requirements.

LANGUAGE SKILL SET DETAILS *

Indicate languages in which you can converse in
Please complete all MANDATORY FIELDS (*) to proceed.

Language – English – Main

Language 1

Language 1 – other than English

Comment on competency in speaking, understanding, reading, writing:

Language 2

Language 2 – other than English

Comment on competency in speaking, understanding, reading, writing:

Language 3

Language 3 – other than English

Comment on competency in speaking, understanding, reading, writing:

RELEVANT EXPERIENCE DETAILS

Previous Work Experience in Developing Countries

If yes – where did you work?

Summary of Work Experience
NB: Include what you did while there and length of stay

Previous Emergency Management or Disaster Relief Training *

What training have you received?
(e.g. CIMS2, CIMS4 or Dip Emergency Management)

Previous Deployment Disaster Relief Experience *

Summary of Work Experience
NB: Include what you did while there and length of stay

Are you a current active member of anther front line health disaster emergency response organisation, or any other organisation’s response team?

Current active member front line team details:
NB: Include name of organisation and what role you play as a member of this organisation

REFERENCE DETAILS

Please complete all MANDATORY FIELDS (*) to proceed.

Reference Details # 1 – Current Manager *

Title

First Name

Surname

Mobile Phone Number

Alternative Phone Number

Preferred Email Address

Your relationship to Reference

Reference Details # 2 (person who has worked with you within the last 5 years *

Title

First Name

Surname

Mobile Phone Number

Alternative Phone Number

Preferred Email Address

Your relationship to Reference

Do you give permission for your references to be contacted? *

AGREEMENT & CONFIRMATION DETAILS

Please complete all MANDATORY FIELDS (*) to proceed.

I have read and understood the Code of Conduct for NZ personnel *

Attached both signed Code of Conduct Forms
Maximum upload file size: 3mb

If deployed I agree to abide by the Code of Conduct for NZ personnel *

I confirm that I have declared any current medical medical and could affect my ability to function effectively in an austere environment*

I understand that the preferred deployments will be of 7 to 14 days duration plus travel time (if required), and that deployment duration may be shortened or (by agreement) extended, and that planned deployments may be cancelled at short or no notice if requirement change *

I agree to work as a team member as directed by the NZMAT Team Leader or his/her delegate(s), and as rostered and scheduled *

I agree to comply with all directions from the NZMAT Mission / Team Lead, or his/her delegate(s), regarding personal or team security precautions or restrictions on on-work activities *

I acknowledge that my work assignments may vary during deployment, and I understand that rosters and schedules may change at short notice according to circumstances and requirements at the time *

I understand that I may work and be accommodated in damaged, austere or less than fully functioning environments *

I understand that I may be required to share accommodation with other NZMAT personnel or live in communal accommodation *

I understand that flexibility, adaptability and willingness to work in new and innovative ways are likely to be required during any deployment *

I understand that some aspects of work during a deployment may involve traumatic sights or actions *

I understand that information provided in this registration form may be shared with health professional organisations to enable the advance selection and deployment of suitable personnel for deployment(s) *

I confirm that I will organise for a criminal vetting be completed if not already completed by current employer *

I confirm that I will organise for a working with children vetting be completed if not already completed by current employer*

PERSONAL DETAILS

CONTACT DETAILS

EMPLOYMENT DETAILS

PROFESSIONAL DETAILS

REGULATORY DETAILS

CITIZENSHIP DETAILS

DRIVER LICENCE DETAILS

MEDICAL / VACCINATION DETAILS

LANGUAGE SKILL SET DETAILS *

RELEVANT EXPERIENCE DETAILS

REFERENCE DETAILS

AGREEMENT & CONFIRMATION DETAILS

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