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, please explain.
*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, please explain.
*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 copy of Board certification (or equivalent ).
*25.
Please upload your Passport.
*26.
Please upload your Passport.
*27.
Please upload your ID.
*28.
Please upload your current copy of diplomas and degrees.
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