INMED - Institute for International Medicine

Institute for International Medicine
Equipping healthcare professionals to serve the forgotten

INMED Diplomat Application

Instructions

Please allow at least 60 minutes to complete this application process and complete all fields. Currently, it is not possible to save your unfinished application and then later return. Be prepared to submit a $50 non-refundable application fee, payable via credit or debit card, or by personal check.

We highly recommend you save a personal copy of your application in case it is not received by INMED. You may save each completed page as a web page, print a hard copy of each completed page, and/or save your responses in a Word document.

Step 1 of 4

Date of application: 7/29/2010

General Information

First name:
Last name:
Age:
E-mail Address:
Alternate E-mail Address:
Home phone:
Mobile phone:
Home Mailing Address Line 1:
Home Mailing Address Line 2:
City:
State
Zip Code:
Country:
Academic Degree:
Specialty/Title:
Occupation:
How did you first hear about INMED?:
Please Describe How You Heard:
Marital status:
Birth date:
Sex:
Country of Citizenship:

Emergency Contact Information

Emergency Contact's First Name:
Emergency Contact's Last Name:
Relationship:
E-mail Address:
Home phone:
Mobile phone:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State:
Zip Code:

Service Schedule

Please list in order of preference 1-3 the dates you are available to serve as an INMED Diplomat:

1. Departing Date Returning Date

2. Departing Date Returning Date

3. Departing Date Returning Date

Institute for International Medicine is a Missouri registered, 501c(3) recognized, non-profit corporation.
INMED is a registered trademark of the Institute for International Medicine.
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