Lumiere Medical Ministries, Inc.
YOU MUST HAVE A SCANNED COPY OF YOUR PASSPORT AND MEDICAL LICENSE before beginning the application as you will be asked to upload them before you can submit your application. Please read each header before filling in the information requested. All items with an * must be filled in; if not, the application will be rejected by the server.
*
First Name
*
Last Name
*
Gender
MALE
FEMALE
Traveling with Spouse
*
Street Address
*
City
*
State/Province
*
Country
*
Zip Code
*
Phone Number
*
Email Address
Team Leader/Organization/Church
*
Team
Passport Information
*
Passport #
*
Date of Birth
*
Date of Issue
*
Expiration Date
*
Issued at
*
Citizenship
USA
Canada
Dominican Republic
France
Haiti
Mexico
Other
YOU MUST UPLOAD A COPY OF YOUR PASSPORT
*
Passport
*
Passport Number
Please call the Director of Field Support at Lumiere if you do not have access to a scanner. 704-823-0271
Emergency Contact and Travel Insurance
EMERGENCY CONTACT
*
First Name
*
Last Name
*
Phone Number
Insurance Beneficiary (cannot be self) and relationship to Volunteer
*
First Name
*
Last Name
*
Relationship
*
Phone Number
*
Email Address
*
Indicates Response Required
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Lumiere Medical Ministries, Inc. *3816-20 S. New Hope Road *
Gastonia, NC 28056
tel. 704-823-0271