PLEASE PRINT or TYPE

PERSONAL INFORMATION:

Name:______________________________________________________________

Mailing Address:_____________________________________________________

City, State/Province:___________Zip Code:________Country:_______________

Name of the Airport(s) to which you have access__________________________

Home Phone:__________________ Cell Phone:____________________________

Work Phone:___________________ FAX Number:__________________________

email address:____________________________

Date of Birth:_________________

Citizenship:___________________  Sex:______________________

Marital Status:________________ Name of Spouse:________________________

Spouse's Date of Birth:______________

Name and ages of Children:____________________________________________

Home Church:________________________ Telephone(   )___________________

Address:____________________________________________________________

Pastor's Name:_____________________ Pastor's Telephone:(   )_____________

HEALTH:

The mission of GANSU, INC is to provide eye care through teaching and surgery to the underserving people living in the remote areas provinces of west China and Tibet. Some parts of these provinces are at very high altitude and some of the passes required in travelling to these areas are at 12,000 feet. In addition to potential health difficulties related to the altitude, general health and sanitation norms are well below the standards expected in the United States. Medications may be difficult or impossible to obtain in a timely fashion.

Please answer the following questions in the context of the above prefacing statements.

Do you take any prescription medications on a regular basis?  Yes____ No_____

If "Yes" what? ______________________________________________________

Do you have a problem that might place limitations on your work in circumstances such as outlined in the prefacing paragraph above? Yes__ No__

If "Yes", please explain:_______________________________________________

Occupation:

Profession:_____________________    Specialty:__________________________

Board Certification:______________________________ Year:________________

Licensing:___________________________________________________________                State or Province

Present position or occupation:________________________________________ 

References: Please provide the name, address, and telephone numbers of  two people who know you in a professional capacity, as well as the same data for two non-family members, other than your pastor, who we can contact for personal referance.

Person to notify in case of emergency:

Name:______________________________Relationship______________________

Address:____________________________________________________________

Daytime Phone:(  )________    Evening Phone:(   )__________________

Volunteer Information:

Previous experience in foreigh countries:_________________________________

___________________________________________________________________

Length of time you can volunteer:______________________________________

Dates available: From____________________ To__________________________

Alternates dates: From___________________ To__________________________

Use a seperate sheet of paper and write a short narrative indicating the following:

     1. How you learned of GANSU, INC.                                             

     2. What you feel you could best contribute to its work.

     3. What would be your personal goals from involvement with GANSU, INC?

     4. What would be your professional goals from involvement with this mission?

     5. Include a statement of your conversion experience, your spiritual beliefs, and what spiritual goals could be realized from affiliation with this China project.

All Volunteers Must Return This Completed Form with: a copy of the photo and informational page of your passport, your list of references, the answers to the above questions, a copy of your State or Provincince Professional License (Medical professionals only) and your Curriculum Vitae (Doctors only).

You can send this information by email but we must have the original application sent to the office. See the addresses listed on the front page of this application.

Signature:_____________________________________ Date:________________