Name (first, middle, last) male  female  Address Citizenship Year of Birth work phone   home phone   fax   cell/pager   email

Profession Specialty Other Relevant Teaching/Clinical Experience Are you board certified/elligible? yes  no  (year   ) Have you ever had a professional license revoked/suspended? yes  no  (explain   ) Languages Spoken: English  French  (other   ) States/Country in which you hold valid licenses/registration Current professional status & institutional affiliation (academic, hospital, retired, private practice, etc.) Please list all prior international experience (country/date/sponsor)

The longest time I could volunteer:  2 weeks   1 month   3 month   6 month   9 month   12 month   Date preferred Alternate dates

Briefly indicate why you are interested in volunteering:

 

Please fax or email your resume or CV to:

The Dikembe Mutombo Foundation, Inc.
P.O. Box 250225, Atlanta, GA 30325-1225
1-866-289-2108 toll free
404-262-2109 phone
404-262-2168 fax
Email: [email protected]