License Acknowledgement

Please complete the below form to join us on one of our upcoming mission trips.

License to Practice*
- I certify that my state license to practice is in good standing, and that there are no actions pending to revoke, suspend, or surrender my license.
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Signature (Upload File)*
Accepted file types: jpg, jpeg, png, gif.
Date*
MM slash DD slash YYYY