This is HTCNE's 3rd
trip to Chiang Mai
Click
Here for Online Registration Form
Only
If a Member of HTCNE
already!
This is a three step
process
Then
-
If New Member
OR to download
the necessary forms
which need
updating
in your personnel
file as indicated on
chart below.
2)~~DOWNLOAD
MEMBERSHIP FORMS
HERE~~
This is to be
completed and mailed
or faxed to the
office
(860) 350 6634 - fax
IF the chart below shows
that a
CV, and or copy of
your medical
license is needed,
please fax or email
them to the office right
away. We need
these to secure your
working permits in
country. See
below for fax
number.
Destination:
Chiang
Mai,
Thailand
Specialty:
Plastic
Surgery
Team Leader:
Dr. Mark
Weinstein |
|
|
Dates:
February
1 - 12,
2006 |
|
|
Sponsor:
Medical
Center
Chiang Mai
University |
|
|
Updates: |
|
Site Contact
Info.: Dr.
Somboon
Chaisrisawadisuk
011-669-956-4030
Maharaj
Nakorn
Chiang Mai
Hospital
Hotel Info:
The
Empress
Hotel,
Chiangmai
199/42 Chang
Klan Road
Chiang Mai
50100
Thailand
Tel. +
(66-53) 270
240
Fax: +
(66-53) 272
467
US
Citizens are
NOT
required
to have a
Visa to
enter
Thailand/
However
Foreign
Travelers
will need to
get their
own
Visas.
Our office
will help
with your
letters,
etc.
See
requirements
below.
See below
for flight
information
BUS:
Also please
note:
There will
be a
transportation
bus paid for
by the teams
funds to
travel round
trip
Yale/JFK for
your
convenience.
Further info
on this will
be posted at
a later
date Credit
Card
Authorizations
/
Please be
sure to
indicate
charges for
Dues/
Airfare
|
Click on any
Team member
name in blue
to send an
e-mail |
|
Administrative
Contact:
Achara
Sessler
203-226-9105
/ w:
203-216-7109
/ Yanisess@aol.com |
Email
Entire
Team |
|
Participants: |
|
|
|
|
|
|
|
|
|
|
|
|
Plastic
Surgeons |
CV |
License
to
Practice
Med.
|
Diploma |
On Line Reg. |
Health
Form
|
Signed
Release |
Passport Info |
Credit
Card
Auth |
2007
Dues |
Airfare |
Total
owed
HTCNE |
|
Mark
H.
Weinstein,
MD Team Leader
|
in
|
in |
in |
in |
in |
in |
in
|
in |
in |
in |
NA |
|
Scott
W.
Barttelbort,
MD
|
in
|
in
|
in |
in
|
in |
in |
in
|
NA |
in
|
self purchased |
NA |
|
Zeno
Noel
Chicarilli,
MD
|
in
|
in |
in |
in |
in |
in |
in
|
in |
cc |
cc |
NA |
|
Stefano
Fusi,
MD
|
in
|
in |
in |
in
|
in |
in
|
in
|
in |
cc |
cc |
NA |
|
Jeffrey
Salomon,
MD
|
in
|
in |
in |
in |
in |
in |
in
|
in
|
in
|
in |
NA |
|
Devinder Singh, MD (RES) |
in |
NA |
in |
in |
in |
in |
in |
in |
in |
in |
NA |
|
Pediatrics |
CV |
License
to
Practice
Med.
|
Diploma |
On Line Reg. |
Health
Form
|
Signed
Release |
Passport Info |
Credit
Card
Auth |
2007
Dues |
Airfare |
Total
Owed
HTCNE |
|
Mary Catherine Birmingham |
in |
in |
in |
in |
in |
in |
in |
in |
in |
self purchased |
NA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Anesthesiology |
CV |
License
to
Practice
Med.
|
Diploma |
On Line Reg. |
Health
Form
|
Signed
Release |
Passport Info |
Credit
Card
Auth |
2007
Dues |
Airfare |
Total
Owed
HTCNE |
|
Brenda Cordova, CRNA |
in |
in |
in |
in |
in |
in |
in |
NA |
in |
in |
NA |
|
Michael Gordon, MD (RES) |
in |
NA |
in |
NA |
in |
in |
in |
in |
in |
in |
NA |
|
David Graboff, CRNA |
in |
in |
in |
in |
in |
in |
in |
NA |
in |
in |
NA |
|
Alyson Hart, CRNA |
in |
in |
in |
in |
in |
in |
in |
NA |
in |
in |
NA |
|
Denis
Hilel
Jablonka,
MD
|
in
|
in |
in |
need |
in |
in |
in
|
in |
in |
in |
NA |
|
Gerald Lefever, MD |
in |
in |
in |
in |
in |
in |
in |
in |
in |
in |
NA |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Nursing/OR
Techs |
CV |
License
to
Practice
Med.
|
Diploma |
On Line Reg. |
Health
Form
|
Signed
Release |
Passport Info |
Credit
Card
Auth |
2007
Dues |
Airfare |
Total
Owed
HTCNE |
|
Ingrid
Crocco,
RN
(OR)
|
in
|
in |
in |
in |
in |
in |
in
|
NA
|
in
|
in
|
NA
|
|
Kerry Digby, PA |
in |
in |
in |
in |
in |
in |
in |
in |
in |
in |
NA |
|
Laurie
Finta,
RN
(OR)
|
in
|
in |
in |
in |
in |
in |
in
|
NA |
in |
in |
NA |
|
Holly Floersheimer |
in |
in |
in |
in |
in |
in |
in |
in |
in |
in |
NA |
|
Maria
Geismar,
RN
(PACU)
|
in |
in |
in |
NA |
in |
in |
in
|
NA |
in
|
in
|
NA
|
|
Lucille Graboff, RN (OR) |
in |
in |
in |
in |
in |
in |
in |
in |
in |
in |
NA |
|
Mary Outtrim, RN |
in |
in |
in |
NA |
in |
in |
in |
in |
in |
in |
NA |
|
Carol
Phillips,
RN
(RR)
|
in
|
in |
in |
NA |
in |
in |
in
|
NA |
in |
in |
NA |
|
John
Tangredi, RN Lead Nurse |
in
|
in |
in |
in |
in |
in |
in
|
NA |
in |
in |
NA |
|
Cathy
Tangredi,
RN
(RR)
|
in
|
in |
in |
in |
in |
in |
in
|
NA |
in |
in |
NA |
|
Sherri Witkins, RN |
in |
in |
in |
in |
in |
in |
in |
NA |
in |
in |
NA |
|
Other
Ancillary
Staff |
CV |
License
to
Practice
Med.
|
NA |
On Line Reg. |
Health
Form
|
Signed
Release |
Passport Info |
Credit
Card
Auth |
| | | | | |
