Registration – Resident & Medical Officer

REGISTRATION – RESIDENT & MEDICAL OFFICERS

This form is for Residents & Medical Officers only. Other Medical Volunteers and Nonmedical Volunteers should fill up a separate form.

Step 1 of 3

This form will take approximately 30 minutes to complete.

Prepare the following documents in legible PDF format before you proceed.

⇀ ID Photo (in JPG format)
⇀ Passport
⇀ CV in English
⇀ Highest Educational Certificate
⇀ Reference Letter
⇀ License
⇀ Speciality Diploma (if applicable)

PERSONAL PARTICUARS

Salutation *

Name *

First

Middle

Last

Preferred Name

How would you like us to address you? Skip if you want us to address you by your first name.

Gender *

Birth Date *

Email *

Your primary email address.

Mobile *

Languages Spoken *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

PASSPORT DETAILS

Passport Type *

Issue Date *

Expiry Date *

Nationality *

Country of Birth *

Place of Birth *

Passport Issuing Authority *

WORK DETAILS

Organisation Name *

If you are currently not working, write 'NA'.

Organisation Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

If you are currently not working, write 'NA'.

Organisation Website

Designation *

Your Speciality *

Have your medical privileges ever been suspended? *

Have you ever participated in any medical missions inside or outside your country? *

Have you been credentialed by other charities that provide cleft surgery? *

REFEREE DETAILS

Your referee may or may not be your current supervisor but should be able to vouch for you at a professional level. Both of you should share the same speciality.

Referee's Salutation *

Referee's Name *

First

Middle

Last

Referee's Email *

Your referee's primary email address.

Referee's Mobile *

Organisation Name *

If your referee is currently not working, write 'NA'.

Referee's Designation *

Referee's Speciality *

Years Known *

Indicate number of years your referee has known you for.

Relationship with Referee *

In what capacity did you work with your referee?

Is your referee a Smile Asia volunteer or official? *

This form will take approximately 30 minutes to complete.

PERSONAL PARTICUARS

PASSPORT DETAILS

WORK DETAILS

REFEREE DETAILS

UPLOADS

Your completed form will be forwarded for review to the Smile Asia Medical Council.

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