VOLUNTEER DENTIST REGISTRATION FORM
This form has to be filled in on an English keyboard only.
Personal Information
Last Name: First Name: Male Female
Address: City: Zipcode:
Country: - Select - United States Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burma (now Myanmar) Burundi Cambodia Cameroon Canada Cape Verde Central African Rep. Chad Chile China Colombia Comoros Congo, Demo. Rep. Congo, Republic of Costa Rica Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Fiji Finland France Gabon Gambia Georgia Germany Ghana Greece Grenada Guadeloupe Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Ivory Coast Jamaica Japan Jordan Kazakstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands, The New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia St. Vincent & Grenad. Samoa San Marino Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Yemen Yugoslavia Zambia Zimbabwe Email: Year of birth:
Phone: Fax: Mobile phone:
Professional Information
Dental School: Year of graduation:
Degree: D.D.S. D.M.D. B.D.Sc. Other
License: State/Country of:
Post-Graduate Training: - Select - Endodontist Pedodontist General Dentistry Periodontist Oral Surgery Other Other:
Are you a member of an Academy of Dentistry? Yes No which:
Volunteering Information
How did you find out about DVI: - Select - Internet professional association news articles brochures or newsletters professional conferences Other Other:
Did a specific colleague refer you to DVI? (Name)
Volunteering preference dates (apartments at DVI are available from Friday to Friday) Friday of arrival: 1. - Select -last minute openings 2. - Select -last minute openings 3. - Select -last minute openings
For how many weeks would you like to volunteer (1 – 4 weeks)? - Select - 1 2 3 4
How many family members are joining you? - Select - 01 2 3 4 Ages:
Would you like to be hosted at a local family for Friday night dinner of your arrival? Yes No
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