Medical Mission Application Form

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Complete Medical Mission Application Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Medical Mission Application Form
Please complete, save and email this application along with an attached copy of your curriculum
vitae to:
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
City: _____________________ Province: _________________ Postal Code: ______________________
Tel. Home #: _______________________________ Tel. Work #: ______________________________
Tel. Mobile #: _______________________________ Tel. Fax #: ________________________________
E-mail Address: ______________________________________________________________________
(Please print your email carefully)
A $500 non-refundable deposit will be charged upon acceptance to a specific mission
Credit Card info (type, number, exp. date, security code):
Professional designation (if applicable): ____________________________________________________
Professional License number (if applicable): ________________________________________________
Organization: ________________________________________________________________________
Mission of interest(s):
□ Benin □ TZ Terrat □ TZ PTE □ TZ Shirati □ TZ Ukerewe □ Uganda
Departure(s): _________________________________________________________________________
Role of interest:
□ Surgeon
□ Physician
□ Nurse
□ Pharmacist
□ Dentist
□ Logistics
□ Other: _______________________
Have you ever participated in a CACHA medical mission before?
□ YES □ NO
If YES, please provide us with the most recent mission name & date:
Mission: _____________________________________________________________________________
Motivation for participating in a CACHA mission:
# 317 - 2310 Blvd. St-Laurent Ottawa, ON K1G 5H9
T 613-234-9992 F 613-248-1881


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