UKREMT Application Form

UKREMT REGISTRATION APPLICATION

All application data is GDPR & HIPAA Compliant
APPLICANT INFORMATION
Full Name *

Prefix First Name Last Name
Date of Birth

/ DD / MM YYYY

Address

Street Address
Street Address Line 2
City	County
Post Code	Country

Mobile Number *

- Country Code - Area Code Phone Number
E-mail *
Type of registration applying for? *
Corporate registrations please email
Grade applied for:
Please leve blank if unsure
Registration

Level 1 ASSOCIATE Registration ( £ 15.00 GBP for the first year then, £ 10.00 GBP for each year.)

Level 2 FULL Registration (Free for first 2yrs only) ( Free one-time payment.)

Total £ 0.00 GBP

PRE-HOSPITAL CARE QUALIFICATIONS
Highest Pre-Hospital Care Qualification? *
All qualifiactions will be audited 100% - please ensure its attached below.
Highest qualification attached: *

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You can upload multiple files and certificates. Cancel of
Other Pre-Hospital Care Qualifications and/or extended skills:
Via certification or CPD (all listed qualifications must be 100% checkable)
All above listed "Other Pre-ospital Care Qualifications" if they have not been upload then please indicate if being sent via seperate email to ukremt@ukremt.org (if not sent or uploaded, we can not use them as evidence - as they can't be audited).

YES - Sent via seperate email NO - Included in attachments No additional qualifications

Evidence - CPD, CV and further information requirements
No. of hours of claimed CPD in last 12 months:
CPD Record attached:

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Curriculum Vitae (CV) Attached:
CV:

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Please remember to attach your CV in Doc, PDF or JPEG format. Cancel of
Blue Light Driving Qualification: *
Name of qualification (If not held please state - none)
Date Achieved:

- Day - Month Year
Date (DD-MM-YYYY)
Blue Light Qualification Attached:

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Please submit in Doc, Docx, PDF, JPG, JPEG, PNG or HTML Cancel of

TERMS & CONDITIONS
Please agree to application T&Cs to continue application:

1. Agree for registration** to be made public on the UKREMT website (** PIN. Name, Qualification, EMT Level & Grade as well as Blue Light Qualification and the Registration expiry date, only - unless T&Cs 4 or 5 are applicable) 2. Agree to read, sign and abide by the Fitness To Practice policy document as a condition of registration (Downloadable from the UKREMT website at www.ukremt.org/fitnesstopractice) FTP Pages 15 & 16 will need to be attached to this application. 3. Agree to abide by the EMT Code as put forward by the UKREMT which can be found on our website (www.ukremt.org). 4. Agree that if a concerned is raised the UKREMT has the right to show this concern as a suspension for up to 12 months or a period not exceeding your current registration period which ever is sooner at this point either reinstatment or a strike order will be applied to your registration. 5. Agree that if you are struck off by the UKREMT that your name will show on the database of registrants as having been struck off - these details will remain visible for a period not exceeding your current registraion period. 6. Agree to pay all your own fees (legal and otherwise) in relation to both this application and ongoing registration this includes and appeals or fitness to practice hearings. 7. Agree under GDPR to recieve emails from UKREMT in relation to your application and registration.
Signed Fitness To Practice (FTP) is attached:

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Pages 15 & 16 Only required Cancel of

REFERENCES & DBS
Please supply up to 2 references, we require at least 1 work (can be instructor, employer or client) reference to move forward on your applicaiton.
Name of Reference 1:
Connection / How known to applicant?
Email address of reference:
example@example.com
Name of Reference 2:
Connection / How known to applicant?
Email address of reference:
example@example.com
DBS Certificate No.
Registered for the DBS gov update service?
DBS Certificate Attached:

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If you do not have a DBS and would like the UKREMT to apply for one for ou please note this can be done for a fee of £59.00 please send a seperate email to DBS@ukremt.org with the subject line UKREMT DBS Application. You will require a DBS either attached or applied for, for your application to be processed as per our FTP.

SIGNATURE
Any additional information you feel would enhance your application please feel free to add it below or send this in a sperate email - with the subject line "Additional Application Information" to info@ukremt.org.
Additional Information:
I authorised the verfication of tall the information on this form, for UKREMT audit team to verify my details for registration and FTP.
Signature Name *

First Name Last Name
Signature *
By submitting this form you agree that all the information contained in it, is accurate to the best of your knowledge and accept that a submission is made regardless of if form is signed and the submission itself will be accepted as your electronic signature.
Should be Empty:

UKREMT REGISTRATION APPLICATION