Note: This is a sample application for short term medical practice licensure by Gansu and Qinghai Provinces. This application must be completed by all of our volunteers physicians, and should be sent to GANSU, INC for transmittal to the respective Health Bureaus prior to the time of departure of each individual physician. Please reproduce the letter below on your office letterhead; include the proper dates where indicated; individualize the statement concerning the province where you will serve, and the documents you are submitting (Note: if this is your first time with GANSU, INC in China then you can state “included with this application are the documents to support my application”, but if this is the second or greater time you have applied for this short term license, then it would be appropriate to state, “you have the documents on hand to support this application”; add your signature block; and mail this application, along with a copy of the following documents: MD diploma, Residency diploma, American Board of Opthalmology diploma, to GANSU, INC by 1 April of the year in which you are serving with GANSU, INC. The application will then be taken, by the first team going to China, to the Public Health Bureau of the respective province, and the short term license will be awaiting you when you arrive in China.
Director, Gansu Health Bureau, # 220 Baiying Road, Lanzhou, 730030, Gansu Province, People’s Republic of China; OR
Director, Qinghai Health Bureau, # 66, Xida Street, Xining, 810000, Qinghai Province, People’s Republic of China
I hereby make application for Licensure by Gansu (or, Qinghai) Province as a Short Term Medical Practice Physician in China. “Included with this application are the documents” to support this application, or, “You have on hand the documents from my previous short term service in China” to support this application. I will be working in Gansu (or, Qinghai) Province with the organization known as GANSU, INC (dba, WEST CHINA VISION PROJECT) for a period of time between April 1 and October 31,(enter year).