Standby EMS Request - MEDICULUM NYC

Standby EMS Request**

**For an event with an attendance estimated to be LESS than 5,000 people.
For events with an estimated 5,000 attendees or more CLICK HERE.

* Indicates required field

Your Organization/Group Name *

Event Coordinator Contact Name *

Contact Phone *

Email *

Organization/Group Address *

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State

Zip Code

Country

Previously contracted with Mediculum? *

Event Name *

Event Location *

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State

Zip Code

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Which option best describes your need for Medical Standby Services? *

How long do you expect to need Standby Medical Services? *

Event Start Date *

Event Start Time *

Event End Date *

Event End Time *

Comment *

Upload Any Additional Information *

Max file size: 20MB

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