Application Form

Sumbit form

Please complete this form to continue your registration to become a Healing Ambassador. Helping us Reaching Every Corner Of Vulnerable Communities In Africa And Asia..

Personal Information

First Name *

Last Name *

Religion *

Application Date: *

Preferred Address for Correspondence

City

State/Province

ZIP / Postal Code

Country

Phone (mobile) *

Phone (work) *

Phone (home) *

Fax *

Personal Email Address *

Professional Email Address *

Select Your Speciality *

Your Speciality

Languages Spoken *

Emergency Contacts (please list two)

How did you hear about Healing Ambassadors? *

Name 1 *

Phone 1 *

Address 1 *

Name 2 *

Phone 2 *

Address 2 *

Professional Information

Current Position: *

Medical School of Graduation *

Dates Attended *

Residency Program *

Date Completed *

Program Director *

Fellowship Program

Date Completed

Program Director

Please describe any previous experience traveling/working in developing countries *

Work-Related References (please list two who can attest to your specific medical abilities and have worked with you in the last two years)

Name 1 *

Phone 1 *

Email Address 1 *

Name 2 *

Phone 2 *

Email Address 2 *

Board Certified

Specialty *

Where taken *

Date Completed *

Board Eligible

Specialty *

Where taken

Date Completed *

Current Medical License Number *

State *

Date issued *

Current Experience (please indicate which types of patients/programs with which you have had experience in the last five years): *

Please describe any previous experience traveling/working in developing countries *

Please answer the following questions:

Are you now or have you ever been involved in any litigation, lawsuits, claims, or arbitration, or are you now involved in any threatened litigation or claim related to your professional activities? *YesNo

Have judgments or settlements been made against you in professional liability cases or are you involved in any pending litigation or denied liability insurance at standard rates? *YesNo

Have you ever been denied liability insurance? *YesNo

Has your membership or renewal thereof in any medical organization ever been revoked, suspended, diminished, or denied? *YesNo

Have your privileges in any hospital ever been suspended, diminished, revoked, denied or not renewed? Have you ever been charged with any crime other than minor traffic violations? *YesNo

Has your license in any jurisdiction ever been limited, suspended, or revoked? *YesNo

Have you ever been subject to any disciplinary proceeding or action by any employer, hospital, or other entity or institution with respect to your professional activities or behavior? *YesNo

Have you ever received treatment, voluntarily or involuntarily for alcoholism or drug abuse, mental illness or psychiatric problems? *YesNo

Do you have any current or past health problems or conditions that would impact or limit your ability to practice medicine in a developing country? *YesNo

If you answered yes to any questions, please provide a brief explanation: *

Please Upload the following items:

Copy of the Educational Certificates (Like Bachelor degree, Diploma, Master, PHD, etc.) *

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Copy of the most recent Medical License *

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Curriculum Vitae including explanation of any time gaps within the last five years *

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Copy of passport (Valid for 6 months at least) or ID *

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