MAP Practitioner Agreement - MAP Medical Mission Program

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an certifying the

Practioner Information

Are you the ordering surgeon? *

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Ordering surgeon's name *

First

Last

Ordering surgeon's phone # *

Ordering surgeon's email *

Medical license # *

Country of active medical license *

If licensed in the USA, which state? (USA only) *

DEA number (USA only)

License expiration date *

If licensed outside the USA, please upload a copy of your active medical license here *

Click or drag a file to this area to upload.

File types allowed:.doc, .xls, .ppt, .pdf, .png, .gif, .jpg Maximum file size 25mb.

If licensed outside the USA, please upload an official letter of privileges from a local hospital certifying you have full clearance to perform surgical procedures using JNJ products you are requesting. As an alternative, you may upload an official letter from the licensing medical board of your country certifying your credentials to perform surgical procedures using JNJ products. *

Click or drag files to this area to upload. You can upload up to 3 files.

File types allowed: .doc, .docx, .pdf. Maximum file size 25mb.

Please provide any additional information regarding your credentials not already listed on this application.

Post-Mission Reporting Agreement

Signature *

Clear Signature

I agree to document the product description, brand name, product code (REF or SKU), lot number, expiration date, and quantity of any product left in-country at the conclusion of my trip. I understand MAP will require this information in the post-mission reporting process *

Today's Date *

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