Any questions or anything to add please include in the Misc section at end of form. Fill out as much as required for the specific service you require. Any questions please contact by email @ asif@canadianparamedicalservices.ca or Canadian Paramedical Services @ 403-259-8399: fax# 403-259-8369.

About The Site

About The Work

• Tentative Start Date
• Tentative Length of contract: remember to specify if number is in days/weeks/months
• Key Contact Name:
• Key Contact Title:
• Job Site or Name:
• Job Location:
• Latitude:
• Longitude:
• LSD:
• Directions:
• Closest City or Town:
• Distance From Closest City Or Town in Kms:

• Type Of Work:Special EventOil & GasMining
• Types of Medics Required:OTHEREMT PEMTEMR
• Coverage period:24 hr12 hr
• Setting:First Aid Un-StockedFirst Aid StockedClinic Un-StockedClinic StockedMTC
• Number Of People On Site:
• Approximate Area Of Site:
• Equipment:CELL PHONEBAG PHONEMTC
• Serial # for BAG PHONE
• Phone # for BAG PHONE
• Serial # for CELL PHONE
• Phone # for CELL PHONE

Logistics

Finance

• Flights Required?: Yes or No
• Meals Included?: Yes or No
• Accommodation Included?: Yes or No
• Fuel Included?: Yes or No

• Travel Days:
• Holidays:
• Crossover Shifts:
• Consumables:
• Service Charge:
• AFE:
• PO#:

Invoicing To Be Sent To:

• Name
• Title:
• Phone:
• Fax:
• Email:
• Notes:

• Name *
• Title: *
• Phone: *
• Fax: *
• Email: *
• Notes

Rates To Be Charged

Final Details

• Service Charge:
• Quoted price:
• Overtime:

• Misc
• Attach File (Optional)