If you are interested in becoming a SIGN volunteer surgeon, please provide the information requested below.
When the information is complete, press the SUBMIT button and your information will be emailed to SIGN Staff.
Fields marked with * are required.
P E R S O N A L    I N F O R M A T I O N
1. Name (first, middle, last):*
2. Gender:*
3. Street Address:*
4. City:*
5. State/Province:*
6. Postal Code:*
7. Work Phone:*
8. Home Phone:  
9. Fax Number:  
10. Cell/Pager:  
11. Email Address:*
12. Citizenship:*
13. Year of Birth:*
14. Profession:*
15. Specialty:*
16. Current Professional Status and Institutional Affiliation (academic, hospital, private practice, retired, etc.):* 
17. Other Relevant Teaching / Clinical Experience: *
18. States in which you hold valid licenses / registration: *
19. Are you board certified eligible? * Yes:  No:   If yes, what year? 
20. Have you ever had a professional license revoked or suspended?   * Yes:  No:
      If yes, please explain: 
21: Medical School: * 22: Degree: *
23: Internship/Residency: *
24: Professional Affiliations: *

E X P E R I E N C E
25. Please list all prior international experience (Country, Date and Sponsor/NGO):*
      

V O L U N T E E R I N G    W I T H    S I G N
26. Briefly indicate why you are interested in volunteering with SIGN. *
      
27. Please describe your experience dealing with trauma. *
      
28. What is your subspecialty of interest?  *
29. Please list when you are able to volunteer and the amount of time you are able to volunteer below.  *
      
30. What countries are you interested (or not interested) in volunteering in?  *
      
31. Can you speak languages other than English? If so, please list them here.  *
32. How did you hear about SIGN Fracture Care International? *
33. Describe who, if anyone, will be accompanying you (spouse, children/ages, other): *
      
34. If you will have a companion, are they interested in serving as a volunteer?  Yes:  No: *
35. At the conclusion of your volunteer trip abroad, are you willing to write us a one-page trip report? * Yes:  No:
36. Do you plan to take photos during your trip? * Yes:  No:
I confirm that the above information is true and accurate to the best of my knowledge.
       

SIGN Fracture Care International | 509.371.1107
451 Hills Street, Suite B, Richland WA 99354
SIGN Fracture Care International is registered as a non-profit, tax-exempt corporation in the State of Washington and in the U.S.A. with IRS 501(c)(3) status. Any financial or in-kind contributions are fully tax-deductible in the United States.

Copyright © 2006 - 2012 SIGN Fracture Care International . All rights reserved.

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