<p>Application Form – ADI Volunteer Papua New Guinea Please complete this form and email to ADI with a copy of your current CV.</p><p>Please select the role(s) you wish to apply for: Volunteer Medical Officer Papua New Guinea</p><p>Volunteer Health Manager Papua New Guinea</p><p>Personal Details</p><p>Title: Family Name: Given Name: </p><p>Street Address: __</p><p>State: Postcode: __</p><p>Phone contacts: Home: Work: </p><p>Mobile : Email: </p><p>Nationality: </p><p>I am a citizen or have Permanent Resident status in Australia New Zealand or PNG</p><p>Hobbies and interests: </p><p>What length of assignment is of interest? 5 – 6 months 11 – 12 months </p><p>What is your availability over the next two years? </p><p>How did you hear about ADI? </p><p>Medical Officer Applicants Only</p><p>Year of Qualification: Medical Specialty: </p><p>Medical Registration Number: State:_____ </p><p>Medical Indemnity Provider: </p><p>Post: P.O. Box 954, Manly NSW 1655 Fax: (02) 8966 9594 Email: [email protected] Health Manager Applicants Only</p><p>Qualification(s) Held: ______Area of Specialty/Interest: ______</p><p>Years of Clinical Experience: ______</p><p>Cross-cultural Experience (location/time): ______</p><p>Referees (ADI will not contact referees without your permission) Please provide the names and details of three referees for your professional work.</p><p>Title: Family Name: Given Name: </p><p>Street Address: </p><p>State: Postcode: </p><p>Phone: Work: Mobile: Email: </p><p>Current position: Professional relationship to you: </p><p>Title: Family Name: Given Name: </p><p>Street Address </p><p>State: Postcode: </p><p>Phone: Work: Mobile: Email: </p><p>Current position: Professional relationship to you: </p><p>Title: Family Name: Given Name: </p><p>Street Address </p><p>State: Postcode: </p><p>Phone: Work: Mobile: Email: </p><p>Current position: Professional relationship to you: </p><p>Post: P.O. Box 954, Manly NSW 1655 Fax: (02) 8966 9594 Email: [email protected] What are your motivations for applying for a volunteer role in PNG?</p><p>Please give details of any previous volunteering experience</p><p>What qualities and capabilities do you feel you can bring to the role you are applying for?</p><p>Post: P.O. Box 954, Manly NSW 1655 Fax: (02) 8966 9594 Email: [email protected]</p>