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    Download this month's BLESSINGS

    Thank you for your interest in our dental services program!

    NOTE: This volunteer application is ONLY for our DENTAL PROGRAM
    in the United States
    .

    At this time, we only need dentists, dental assistants, dental hygienists and nurses to volunteer. We are NOT recruiting teams to send to tsunami disaster areas or join international medical teams. Operation Blessing's international outreach centers have a network of medical professionals already living in their region that volunteer for their specific medical needs.
    DENTAL VOLUNTEER REGISTRATION

    I would like to volunteer as..

    Nurse
    Dentist
    Dental Assistant
    Dental Hygienist

    General Information

    Name*
    Home Phone*
    Work Phone*
    Address 1*
    Address 2*
    City*
    State*
    Zip*
    Email*
    Fax

    Specialty and License Information

    Please list all states in which you are licensed.

    Specialty
    State
    License #
    Exp. Date
    please list all states in which you are licensed

    Education

    Educational InstitutionYear of Graduation
    Degrees/Certification
    Educational InstitutionYear of Graduation
    Degrees/Certification
    Educational InstitutionYear of Graduation
    Degrees/Certification

    References

    Please submit one pastoral or community reference and two professional references who are acquainted with your work and have recently worked with you.

    Pastoral or Community Reference

    Name:
    Address:
    Phone:


    Professional Reference

    Name:
    Address:
    Phone:

    Professional Reference


    Name:
    Address:
    Phone:

    Comments

    Are you active U.S. military? No Yes (This is required by the Division of Risk Management)

    Comments

     

    Operation Blessing Contact


    Karen Ball..............(757) 226-3858

    Please click SUBMIT to send your registration directly to Operation Blessing.



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