Volunteers Application Form

Dental Volunteers Application Form

Please fill out the following form or print and mail (PDF).

We are officially selected by the ADA as part of their International Dental Volunteer Organizations

	We need talent and we know dentists have what it takes!!! "Yes! My interest in the Trudi Birger Dental Clinic has become greater." Last Name: * First Name: * Gender Male Female Home Address * City * State * Zip Code Country * E-mail * Year of Birth Place of Birth Home Phone Home Fax Mobile Phone Office Phone Office Fax Other Phone Languages you Speak (mother tongue first) Dental School Year of Graduation Degree D.D.S. D.M.D. B.D.Sc. Other Other State/Country of License License Number Post-Graduate Training Specialty Program Are you a member of an Academy of Dentistry? 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 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. 2. 3. Numbers of Weeks Available to Volunteer How many family members are joining you? Ages: Comments: