Our Medical Professional Volunteer Application at the Moore Free Care Clinic

Medical Professional Volunteer Application

Fill out and submit the online application below, or
fill out the printable application and send it to us at:

Moore Free Care Clinic
Volunteer Coordinator
P.O. Box 1656
Carthage, NC 28327-1656

Phone: (910) 947-6550
Fax: (540) 947-6551
Email: Director

Title:

Dr.

Mr.

Mrs.

Ms.

Rev.

First Name:
M.I.:
Last Name:
Social Security Number:	(xxx-xx-xxxx)
Nickname:
Medical Training:	Physician Nurse Other
Can we add your email address to our contact list? Yes No
Street Address:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Fax:
Email:	* email address required
License Number:
Please fax us a copy of your license to (910) 947-6551 Att: Clinic Director
Your present employer:
Personal Liability Insurance with (company name):

State briefly why you wish to volunteer for the Free Clinic:

List any other volunteer experiences you've had:

Comments:

Contact In Case of Emergency:
Name:
Relationship:
Address:
Phone Number:
We are respectfully requesting that you submit the names and contact information for two non-relative references:
Reference One:
Reference Two: