Pensum

[pic]


Application Form

Medical Brigades in NPH-Homes


1- Personal information of the participants (attach additional sheets as needed):

Full Name Male/ Age Profession*Level of *Level of
Female Spanish French/Creole

1. _________________________ ______ ____ ______________ ________ _________

2. _________________________ __________ ______________ ________ _________

3. _________________________ ______ ____ ______________ ________ _________

4. _________________________ ______ ____ ______________ _________________

5. _________________________ ______ ____ ______________ ________ _________


* 0 = no knowledge, 1 = basic knowledge, 2 = mid level, 3 = fluent

Please attach a copy ofdiploma(s), certificate(s), or license(s) for those who hold them, and a resume or CV for the group leader

2- Contact Information
a. Contacts of your organization (if you come throughanother organization):

Name of your organization: ___________________________________________________
Address of your organization: __________________________________________________Business Email address: ______________________________________________________
Business Phone number: ______________________________________________________

b. Personal contact Information(of one contact person for your group):

Name: _____________________________________________________________________
Address:___________________________________________________________________
Email address: _______________________________________________________________
Phone number: ______________________________________________________________




3- Knowledge,skills and abilities:
Please list professional skills, licensure, and/or background of the group leader and group.
___________________________________________________________________________...