Volunteer Registration Form _test2

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Last Name:*

First Name:*

Gender

Male
Female

Languages Spoken: (mother tongue first)

Address

Street Address:

City/Town:

Postal Code:

Country:

Contact Information:

E-mail:

Home Phone:

Office Phone:

Mobile Phone:

Fax:

Religion:

 (This information will only be used to suggest touring options, etc. that are relevant for you)

Professional Information:

Dental School:

Year Graduated:

Please note that we can only accept volunteer dentists with a full two years experience – minimum

Degree:

D.D.S.
D.M.D.
B.D.Sc.
Other

Other Info:

Country of License:

License Number:

Post-Graduate Training:

Specialty Program:

Specific Specialty

Endodontist
Pedodontist
General Dentistry
Periodontist
Oral Sugery
Other:

Are you a member of a Dental Association/Academy?

Yes
No

Which?

Private Practice?

Yes
No

Number of Hours per Week:

Dental Clinic Address:

Do you treat children?

Yes
No

Approx. percentage of practice treating children:

How did you find out about DVI?

Internet
Professional Association
News articles or Brochures
Professional ConferencesOther:

Did a specific colleague refer you to DVI?

Name:

Preferred Volunteering Dates:

(note: apartments at DVI are available from Friday to Friday)

Preferred Volunteering Dates:

(note: apartments at DVI are available from Friday to Friday)

Friday of Arrival – First choice: Friday of Arrival – Second choice: Friday of Arrival – Third choice:

Number of weeks available to volunteer:

How many family members are joining you:

Their ages:

Comments:


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