INTERNATIONAL MEDICAL VOLUNTEER APPLICATION

1.
Full Name*
2.
Gender*
3.
Date of Birth*
4.
Country*
5.
Phone Number*
6.
Email Address*
7.
Home Address*
8.
WORK INFORMATION*
Name of Work Hospital
Positional Title
Work Address
9.
EMERGENCY CONTACT*
Name
Contact Number
Relationship
10.
Please select from the following specialties.*
  • *
     (Plastic, ENT, Oral or Pediatric surgeon)
12.
Please indicate which types of patients/programs you have had experience with in the last 3 ‑ 5 years.* 【Multiple】
Choose at least ONE option
13.
Current job description :*
14.
Do you have registered license?*
If YES, please fill in your specialty and certified date.
  • *
15.
Do you still practice in your stated specialty?*
16.
Have your medical privileges ever been suspended?*
If YES, explain it.
  • *
17.
Do you have BLS certification?*
If YES, please write the certified date.
  • *
18.
Do you have PALS certification?*
If YES, please write the certified date.
  • *
19.
Do you have ACLS certification?*
If YES, please write the certified date.
  • *
20.
Have you ever participated in any overseas medical/healthcare work?*
If YES, explain it.
  • *
21.
Foreign languages and sign language (please indicate level of fluency):*
22.
Please provide information for an individual from within your specialty who can attest to your clinical ability, professionalism, and ability to work as a part of a team in high-stress situations. *
One Reference must be needed and he/she should be our current credentialed volunteer.
Name
Position
Company/Hospital
City, State, Country
Telephone Number
Email
For how long did you work closely with this reference?
In what capacity did you work with this reference?
Is this reference a Smile Mission volunteer?
23.
Please upload your current curriculum vitae/resume.*
24.
Please upload your current copies of licensure.*
25.
Please upload your current copy of Board certification (or equivalent).
26.
Please upload your Passport.*
27.
Please upload your ID.*
28.
Please upload your current copy of diplomas and degrees.*
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