Volunteer Form

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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

MaleFemale

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 DentistryEndodontistPedodontistPeriodontistOral Surgery
Are you a member of an Academy of Dentistry: YesNo

Currently Practicing Dentist (required)? YesNo
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: InternetProfessional AssociationNews ArticlesBrochures or NewslettersProfessional Conferences
Did a colleague refer you to DVI? (name)
Religion:
Would you be willing to help DVI fundraise in your area? yesno

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):12
How many family members are joining you?:
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Ages?:

Your Message

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