Yes, add me to the IMHO yahoogroups email list
No, do not add me to the IMHO yahoogroups email list

I prefer to receive announcements by email
I prefer to receive announcements by US postal mail

Select One Medicine Surgery Nursing Dietician Lab Technician Pharmacist Physiotherapy Radiology Technician Respiratory Technician Other Non-healthcare field

If other, please specify

Subspecialization        

Number of years experience in USA elsewhere

If elsewhere, please specify countries

Have you worked in an NGO or a volunteer organization?

Yes No

Organization Number of years

Positions Held/Duties/Skills

Are you willing to work in North-East Sri Lanka for 2 weeks in a year?

Yes No Not Sure

If yes, will you make this an annual commitment?

Yes No Not Sure

Are you willing to work in North-East Sri Lanka for more than 2 weeks in a year?

Yes No Not Sure

If yes, for how long?

Are you willing to teach, lecture, or train healthcare students in North-East Sri Lanka?

Yes No Not Sure

Are you willing to finance projects partially or fully in North-East Sri Lanka?

Yes No Not Sure

How much are you willing to contribute to building a primary healthcare center in North-East Sri Lanka? [building cost is about $50,000 and monthly running cost is about $3,000]

$1,000 $500 Any other amount, please specify $

Please make checks payable to "IMHO" [International Medical Health Organization]

Please inform your friends about IMHO and/or provide us with their contact details.

Name Email/phone

Name Email/phone

Name Email/phone