Provider Volunteer Information

Name*

First

Last

Date of Birth

day

/

month

/

year

Phone*

Email*

Address*

Street Address City State / Province / Region Postal / Zip Code

Select your Position*

MD

PA

NP

Other*

*Other Area of Practice

Volunteer physicians must have current licensure in Georgia. Not holding malpractice insurance does not prevent volunteer providers from serving at Good Sam.

Are you already covered by malpractice insurance?

Yes

No

License Number

Please tell us why you would like to volunteer at Good Sam?*

Please tell us how you heard about Good Sam?*

PLEASE PROVIDE US WITH TWO PROFESSIONAL REFERENCES

REFERENCE 1 INFORMATION

Reference 1 Title and Name*

Title

First

Last

Relationship*

Professional Reference 1 Email*

REFERENCE 2 INFORMATION

Professional Reference 1 Phone*

Reference 2 Information*

Title

First

Last

Reference 2 Relationship*

Reference 2 Information Email*

Reference 2 Information Phone*