* 1. Date (MM/DD/YYYY):

The date of this application is:

* 2. Unique ID Number:
To create your Unique ID Number, use the two digits of your month of your birth, the two digits of day of your birth, and the last four digits of your social security number. For example, May 29, 123-45-6789 has the ID number 05296789.

* 3. To apply for the Pennsylvania/MidAtlantic AETC's clinical training program applicants must furnish the following documentation (application cannot be processed unless all items are completed and returned). The c.v., copy of license and letter(s) should be sent to: Pennsylvania/MidAtlantic AIDS ETC, A 461 Crabtree Hall, Graduate School of Public Health, University of Pittsburgh, 130 DeSoto Street, Pittsburgh, PA 15261.