Fill out the following Medical Professional application below and send it to us at:

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

Personal & Contact Information

Title:     Dr.     Mr.     Mrs.     Ms.     Rev.

First Name: ________________________ M.I. ____

Last Name: ________________________________

Nickname: _________________________________

Degree/Credentials: _________________________

Street Address: _____________________________

City: _________________ State: ___ Zip: ________

Home Phone: _______________________________

Work Phone: _______________________________

Fax: ______________________________________

Email: _____________________________________

License Number: _________________________

Please fax us a copy of your license to (910) 947-6551 Att:TJ

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: _________________________________

Signature: __________________ Date: _____________