If you want to volunteer the activities of Dr. Purabi’s Help Desk please fill up and submit the form. Volunteer Volunteer/Intern General Application General information Name * Address Contact Number * Email Address * National ID Card Number * Emergency Contact Number 1. Skills and Interests Educational Background Licensure/Certification Present and Pervious Occupation Volunteer or Intern Experience Hobbies, Interest, Skills Are you proficient in any language other than Bengali ( please specify )? 2. Please note the programs that interests you Adolescent health changesHealth & hygiene during menstruationContraceptionCancer screeningMaternal health & well beingLifestyle modifiactionVaccinationNutrition & Mental HealthAdministration Other 3. Please indicate any other special skills or qualifications you would like you use: Marketing/PROffice SkillsReceptionistPublic SpeakingCounsellingCooking Other 4. Availability When are you available? SatSunMonTuesWedThursFri How many months can you commit? Do you have a geographic preference as where you would like to be placed? Do you have reliable transportaion readily available for volunteer/intern work? YesNo 5. References Name Address Contact Number 6. Miscellaneous Have you ever been convicted of any law violation ( except a minor traffic violation )? YesNo ( A criminal history record check and a background check for child abuse an neglect are done on all volunteers and interns working with youth under the age of 18 ) How did you hear about us? Saw job description/flyerVolunteer ConnectionReffered by a friend/volunterPress release in local newspaper Other I hereby apply for volunteer with Dr.Purabi's help desk. I understand that background checks for criminal history and/or child abuse and neglect may be conducted, and I authorize the volunteer services office to contact the references listed in this application. Photo Karimas Plaza, 105 Boro Moghbazar, Flat-D-4, Dhaka 1217, Bangladesh Email: dr.purabi@yahoo.com Dr.Purabi's Help Desk Section VerificationPlease enter any two digitsExample: 12This box is for spam protection - please leave it blank