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BARBUDA PHYSICIAN ORGANIZATION

Application to Barbuda Physician Organization 

I,____________________________________, M.D. , D.O. hereby make application to be a volunteer physician to the island of Barbuda as part of the BPO for the month that I have accepted. 

I am a duly licensed physician in the state (Province) of _____________________ in the country of _______________________. 

My application processing, membership fee of $100.00 is included.  A check should be made out to Barbuda Physician Organization. 

I understand that Barbuda is a relatively safe island, however accidents and unforeseen events may occur and I or members of my family or my guests will hold no one associated with the Barbuda Physician’s Organization or Barbuda Medial Program responsible for any untoward events that may happen on Barbuda, or traveling to and from Barbuda. 

I understand that it is my responsibility to get an acceptable replacement if I am unable to keep my commitment to go to Barbuda on the month that I have been assigned and accepted.

Have you ever been indicted, arrested or convicted of a drug violation (including DUI) or a felony? 

                    Yes___________    No____________

Have you had your license or privileges suspended or encumbered in any way? 

                    Yes___________    No____________

If your answer was yes to either of the previous two questions, please explain fully

on separate page.

_________________________________________       NAME   (TYPE OR PRINT)

_________________________________________       SIGNATURE

_________________________________________       DEA #

_________________________________________       STATE LICENSE

______________________________________        HOME PHONE

______________________________________        CELL PHONE

_________________________________________       OFFICE PHONE

_________________________________________       FAX

.

                 Barbuda Physicians Organization

                 1212B Van Voorhis Rd

                 Morgantown, WV  26505

                 Office Phone: 1-304-598-0363

                 Fax: 1-304-598-0473 

                 Home Phone: 1-304-599-9550

Last modified: June 22, 2007