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Volunteer Dentist Application Form

We are grateful that you are interested in volunteering with us at the Trudi Birger Dental Clinic in Jerusalem. The important work that you do will help many needy children in Israel smile again. We will respond to you within 7 days to inform you whether your application has been approved.

You can fill in the information on line and click submit.

Please note that we can only accept volunteer dentists with a full two years’ experience on their licenses. Dental hygienists or dental assistants cannot apply to volunteer due to the licensing restrictions from the Ministry of Health.

Personal Information

Your Name (required)

Your Email (required)

First Name

Last Name

 Male Female

Home Address (required):

City State & Zip (required):

Country (required):

Date of Birth:

Phone:

Fax:

Mobile:

Professional Information:

Dental School (required):
Year Graduated (required):
 D.D.S. D.M.D. B.D.Sc. Other
License: (Including State/Country of)
 General Dentistry Endodontist Pedodontist Periodontist Oral Surgery
Are you a member of an Academy of Dentistry:  Yes No

Currently Practicing Dentist (required)?  Yes No
Please attach a photocopy of your current dental license:
If you are a specialist, please attach relevant documentation:
If you'd like, please attach a 250 x 300 pixel photograph of yourself:

Please note: there should be at least one month between the end of your volunteering and when your license expires.

Volunteering Information

How did you find out about DVI:  Internet Professional Association News Articles Brochures or Newsletters Professional Conferences
Did a colleague refer you to DVI? (name)
Religion:
Would you be willing to help DVI fundraise in your area?  yes no

Volunteering preference dates (apartments at DVI are available from Friday to Friday). Volunteering is from Sunday to Thursday.

Friday of arrival:
First Choice:
Second Choice:
Third Choice:
How many weeks would you like to volunteer (1 or 2 weeks): 1 2
How many family members are joining you?:
 1 2 3 4 5
Ages?:

Your Message

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