MA Responds:

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Account Information

Creating an account is the first step in the MA Responds registration process. You will use your account username and password each time you log into MA Responds.

Username:

The username must be at least six (6) characters long and cannot contain spaces. Acceptable characters include alphanumeric (A-Z, 0-9) and the symbols @, ., -, and _. Usernames are not case sensitive.

Password:

Confirm Password:

Secret Question:

Secret Answer:

Terms of Service and Privacy Policy

Required field Terms of Service:

By checking this box, I indicate that I agree to the Terms of Service and have read and understand the Privacy Policy for this site. My submission of this form will constitute my consent to the collection and use of this information and the transfer of this information across the Internet to processing and storage facilities supporting this system. I also agree to receive required administrative and legal notices such as this electronically.

Required field Information Pledge:

By checking this box, I pledge to provide only correct information when completing this registration process. I also give consent to MA Responds and their designated agents to collect, use, verify, and maintain any information that is collected through the use of this site.

Required field Background Check Consent:

I hereby authorize MA Responds and its designated representatives to investigate my background and qualifications for the purpose of determining whether I am qualified for the position(s), volunteer or employment, for which I am applying. This authorization will be effective on the date I create my profile in this electronic registry and will remain in effect until my account is terminated, in writing (via email or letter), by me or MA Responds. I understand MA Responds will conduct such background investigation with the assistance of one or more outside firms and the scope of this investigation will include, but not be limited to, employment history, education history, driver’s license records, public records of civil and criminal history, and professional licensing and credentialing. I understand that MA Responds and its representatives will use the personal data entered by me into this electronic registry to conduct the background investigation. I certify that the information provided is, to the best of my knowledge, true and accurate. I further understand any mistakes or incorrect information in the personal data provided by me may affect the accuracy of any background investigation.

Name and Address

Prefix:

Example: Dr., Col., Mr., Mrs., Ms.

First Name:

Middle Name:

Last Name:

Nickname:

Suffix:

Example: Jr., Sr., MD., PhD, RN

Maiden Name:

Home Address Line 1:

Home Address Line 2:

City:

State:

Zip Code:

Work State:

Alternate Address Line 1:

Alternate Address Line 2:

City:

State:

County:

Zip Code:

Identifying Information

Date of Birth:

Social Security Number:

SSN is used to verify certain licensure information and for identification purposes. Last 6 digits only.

Gender:

Contact Information

Primary Email Address

Delete

Email Address:

If you have an email account, it is important for you to provide this information. Without your email address, you may miss important messages and notifications. Please note that the system will not allow two accounts with the same email address. If you do not have an email address or your email address is already registered with the system, you can learn more about obtaining a free email address by clicking here.

Confirm Email Address:

Add Email Address

Contact Method 1

Delete

Contact Method 1:

Number to Attempt:

x

Pager Type:

Pager Carrier:

Pager ID/PIN:

Add Another Contact Method

Occupation Information

What is your occupation type?

Occupation:

If your occupation does not appear in the list, please select Other.

What is your current professional status for this occupation?

Driver's License Endorsements

Indicate all driver's license endorsements for operating motorized vehicles.

Licensed to operate:

a passenger vehicle a motorcycle a single commercial motor vehicle over 26,000 lbs a combination commercial motor vehicle over 26,000 lbs other commercial vehicles and buses

Are you certified to transport hazardous materials?

Yes No

Registration Feedback

How did you hear about the site?

if Other/Website, please specify in the comments.

Comments:

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