FlyingSamaritans

Los Amigos Chapter

 

 

Create an electronic CV by filling in the requested information below:

PURPOSE;  Mexican law requires that American healthcare professionals who are volunteering their professional healthcare skills in Baja California Sur be a current  member of the Flying Samaritans and, through the Los Amigos Chapter, provide detailed information pertaining to their current qualifications to practice .  This requirement pertains to all licensed healthcare providers.

The information provided on this form will be used only for its intended purpose of satisfying the requirement of the BCS Secretary of Health and will not be used for any other purpose.

In addition to completing this form, you must MAIL a clear copy of your professional license to: 

The Flying Samaritans, P.O. Box 13613,  Mesa, AZ  85216.   

Fax'd copies of a license are usually unreadable, so we no longer accept a fax'd copy.  However, if you prefer, you can scan a copy of your license and email it to:  Mshottair@cox.net.

If  you have questions regarding this form, please contact the specialty coordinator listed below.

Medical Coord.

 

Chiropractic Coord.

Gail Brown

 

Patricia Henthorn

   

Dental Coord.

   

 

Corinna McClure

 

Pharmacy Coord.

 

Optometry Coord.

Gail Brown

  

Amy Crump

   

Audiology Coord.

   

 

David Bryman

 

Licensed medical providers will not be able to participate at a Flying Samaritans clinic in Baja California Sur until this information is on file with the Secretary of Health, BCS.     Processing time is 2 or more weeks, so please allow time for the form to be processed prior to your intended trip.  We only require that the CV be completed one time.  If your information changes significantly, please resubmit the form.

Personal Information

Note:  Reference to "Medical" includes all Medical fields, including 

Chiropractic, Pharmacy, Optometry and Dental.

IMPORTANT !  When moving from block to block on this form, use the 'Tab' key, not the 'Enter key'.

 

First Name

 

 Your name as it appears on your license.                                                                                                             

Last Name

 

Middle Name

 

Title:

 (Medical related title, such as MD, DO, DC, DDS, NP, etc)

 

Specialty

 

 

City

 

State

Zip

Academic Background/Licenses/Certifications

 

Professional License / Certifications

Include license or certificate number

 

Medical/Dental School

 

Year of Graduation

 

Internship

 

Residency

 

   

In which states do you hold a medical/dental license?

  List all states that apply.

 
   
Current Employer   Employed since (year)
 

Previous Employer:

  

  Employment Dates:

 

Check One:

MEDICAL  

DENTAL   

PHARMACY 

CHIROPRACTIC 

OPTICAL 

OTHER 

DESCRIBE "OTHER" 

 

  
Professional Certifications

 
 

Additional Employment History:
   
  Please note:  It is possible for the information contained on this form to be found via a search engine such as Google or Yahoo.  We have tried to not ask for any information that could be used in identity theft.  What you complete on this form is entirely up to you.  However, in order for you to practice in Mexico it is necessary that we provide the Mexican government with a brief resume of your background.  Via our website we will be sending the information you provide to La Paz and they will make the determination on weather you may practice in Baja.

Please indicate that you have read and understand the above statement.

Yes I have read and understand the above statement .

If you have a problem submitting this form please contact the webmaster:  mshottair@cox.net