Field Volunteering Application
Form
Please complete this application in English
1. Personal Information
Last Name
(as shown on passport)
Gender
Male
First Name(s)
(as shown on passport)
Date of Birth (mm-dd-yy)
Place (city, country) of Birth
Female
Telephone Number
(home)
Telephone Number
(Mobile)
Fax Number
E-mail Address
Permanent Address
Current/ Mailing
Address
(if different from above)
Citizenship
Date of expiry (mmdd-yy)
Passport
1.
Yes
No
2.
Yes
Profession
Applying Position (please select from the list given below)
No
Passport No:
Passport No:
Medical
Paramedical
Non-medical
Medical:
anesthesiologist pediatrician / physician surgeon
obstretician/gynaecologist, community health specialist other (pls. specify:
______________________________ )
Paramedical:
epidemiologist mental health officer midwife nurse laboratory scientist
other (pls. specify: __________________________________________________________ )
Non-medical:
financial co-ordinator logistician water/ sanitation specialist
other (pls. specify: __________________________________________________________ )
2. Availability to go to the field
From
Until
Do you consider a career with MSF?
Yes
No
Dont know
Are there any countries or conditions you do NOT wish to work in? If yes, explain your reason(s)
briefly; if no, type none.
How much notice do you need for a non-emergency
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day (s) / week (s)
departure?
In case of an emergency mission, how much notice do
you need?
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Day (s) / week (s)
3. Additional Information
Have you applied to work for MSF before?
No
Yes (when and where: ______________ )
How did you hear about MSF?
Radio
Journal
Friend/Co-worker
TV
Internet
Other (pls. specify: _________ )
Did you attend any of our info or sharing sessions?
If so, when and where? (month/year)
4. Motivation
If insufficient space, attach a separate sheet
Why do you want to work for MSF?
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5. Education and Training
Field of Study and
Type of Training
If insufficient space, attach a separate sheet
Name of Institute or
University, City,
Country
Date of Attendance
(month/year)
Degrees/ Certifications
Obtained
1.
2.
3.
4.
5.
6. Professional Experience
(please start with your present or most recent employment and work backwards, do not write see CV) if
insufficient space, attach a separate sheet)
Are you currently
employed?
Name of Employer/
Organization
No
Yes (please specify: _____________)
Position and Nature of Work
From
Till
(month / year)
1.
2.
3.
4.
5.
7. Travel Experience Overseas
(including working, volunteering, traveling experience, especially in developing countries) if insufficient
space, attach a separate sheet)
Location
Type of Experience
Duration
1.
2.
3.
4.
5.
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8. For All Applicants
Are there particular types of project(s) or position(s) that interest you?
What experience do you have in supervision, human resources management and/or training?
Please check the box(es) in which you have work experience:
Computer skills
Word
Epi programs
Excel
Others (pls. specify __________)
PowerPoint
Outlook express
8A. For Medical and Paramedical Applicants
(Mental Health Officer only require to fill in registration number)
Medical Professional Body and Current Registration Number(s)
Have you taken a
course in tropical
medicine?
Yes
When and where?
No
___________________________
Do you intend to? If so,
when and where?
Please check the box(es) in which you have work experience (after completion of M.B.B.S):
Tropical Medicine
Infectious Diseases
Public Health
Other
Kala Azar
TB
Vaccination Campaign
Obstetrics/Gynecology
Malaria
HIV/AIDS
Malnutrition
Mental Health
Sleeping Sickness
STI
Mother & Child Health
Pediatrics
Epidemiology
General Surgery
Cholera
Other (please specify):
8B. For Logistician Applicants
How would you rate your knowledge of the following,
check the boxes accordingly:
Extensi
ve
Modera
te
Basic
None
Maintenance of pumps and generators
Motor vehicle maintenance
Energy/ Electricity
Radio equipment operation
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Construction & building
Cold chain management
Water & sanitation
Information technology (computer)
Warehouse and supply
Medical equipment
Book-keeping
N.B. Some Non-medical applicants will be required to sit a technical test at the interview stages.
9. Professional References
(minimum two referees, including one from your most recent employer, if possible)
Name of Referee
Relationship
Organization
Contact
number(s)
1.
2.
E-mail Address
10. Languages
Mother Tongue
How would you rate your knowledge of the following, check the boxes accordingly: Fluency
Language
Fluent
(sometimes
forget the
language that
you are
speaking)
Good
(can teach
someone
basics of the
language)
Fair
(can discuss
menu with
waiter and
give directions)
Poor
(can find a
bathroom and
read menu)
None
(has no knowledge
of that language
whatsoever)
English
French
Portuguese
Spanish
Other
Other
By checking this box, I hereby certify that the above information is true, correct and complete. I also declare
that I understand the privacy policy of Mdecins Sans Frontires India.
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Signature (required only if
printed)
Date
Place (city, country)
To process your application more efficiently, we request that you submit
an electronic copy of your rsum/CV (in PDF or Word format) along with
this completed form via e-mail. If you are unable to send your documents
electronically, please post them to:
Human Resources Department
Mdecins Sans Frontires India
Visiting Address:
AISF Building
1st Floor ,Amar Colony
Lajpat Nagar-4
New Delhi, India - 110024
Tel: +91-1141555940
Tel: +91-9910405492
Email:
india.office.hrm@new-delhi.msf.org
www.msfindia.in
:: Privacy Policy ::
All personal information provided to Mdecins Sans Frontires (MSF) is
kept confidential. All personal information is for the sole purpose of MSF
volunteer recruitment activity and management. This includes the
sharing of information with other MSF operational centers, partner
sections and/or field missions. No information will be provided or shared
with external parties without the permission of the applicants/
volunteers. Applicants/volunteers have the right to request access to and
correction of their personal data. The request must be submitted in
writing to the Human Resources Department.
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Checklist
Make sure you have all the
necessary documents when
submitting your application:
Five pages of completed
application form
Updated and detailed
CV (not longer than 3
pages)
Photograph (optional)
Need to Know
It is our aim to have your
application screened within
three
business
weeks.
However,
due
to
large
amount
of
applications
received, longer waiting time
may
sometimes
be
anticipated. If you do not
hear from us in three weeks,
please feel free to contact us
for an update on the status
of your application. ONLY
COMPLETE APPLICATIONS WILL BE
SCREENED.
