Destination:
Barajona, Dominican
Republic
Home ::
DOWNLOAD
MEMBERSHIP FORMS
HERE
This is to be
completed and faxed to the
HTCNE office
Immediately
(860) 350 6634 - fax
Next:
Click
Here for Online Registration
IF the chart below shows
that a
CV, Medical
License, Med. School
Diploma, or
Delineation of
Privileges is needed,
please fax or email
them to the office right
away. We need
these to secure your
working permits in
country.
(860) 350 6634 - fax
Please scan and
email your passport
photo page to
Missy
Destination:
Barajona,
Dominican
Republic
Specialty:
Medical
Assessment,
Peds., OBGYN
Team Leader:
Dr. Karen
DiPasquale |
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Dates:
Jan. 26 -
Feb. 2, 2008 |
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Sponsor:
Dominican
Literacy
Project |
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Updates: |
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Site Contact
Info.:
Kim Crandall
Hotel Info:
See below
for flight
information |
Click on any
Team member
name in blue
to send an
e-mail |
Administrative
Contact:
Andrea
Peters
Team
Administrator
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Email entire
team |
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Participants: |
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Medical Staff |
License to Practice |
Curriculum
Vitae
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Diploma
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Privilege
Delineation |
Clinical
Specialty |
Health
Form
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Signed
Release |
Passport Info |
Credit
Card
Auth |
2008 Dues |
Itin |
Airfare |
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Mary Babikian, Pediatrics |
in |
in |
in |
|
in |
in |
in |
in |
in |
cc |
in |
paid |
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Erin Dawson-Chalat |
in |
in |
in |
in |
in |
in |
in |
in |
in |
cc |
in |
change fee only
due |
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Karen DiPasquale |
need
one
on
file
is
x
2006 |
in |
need
-
did
not
have
from
prev
trips |
in |
in |
in |
in |
in |
in |
cc |
need |
paid |
|
Jennifer Drake |
NA |
NA |
NA |
NA |
NA |
in |
in |
in |
in |
cc |
in |
paid |
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Claudette Mimeault |
need |
need |
need |
NA |
in |
need |
need |
in |
need |
cc |
in |
change fee only
due |
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Jennifer Drake: 1/26/08 JFK, NY 9:30 AM - AA flight 1529 - Arrive Santo Domingo 2:35PM
2/6/08 Santo Domingo 3:50 PM - AA flight 158 - Arrive JFK 6:55PMClaudette Mimeault
Erin Dawsonchalat
Mary Babikian 1/26/08 7:10 AM Portland, ME - U.S. Airways Flight 3195 - arrive Philadelphia 8:57AM
1/26/08 9:40AM Philadelphia, PA airbus A319 - Santo Domingo, DR - arrive 2:37PM
Return 2/2/08 3:30PM Santo Domingo DR Airbus A319 arrive Philadelphia 6:25
2/2/08 9:00PM Philadelphia, Pa Flight 3194 arrive Portland, ME 10:37 PM |
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Fax Forms to HTC
at 860-350-6634
Mail Forms to HTC at
P.O. Box 129, New
Milford, CT 06776
E-mail to mlaw@htcne.org |
