Please complete this form to submit general information and a personal statement for your application. Please also email your CV, training curricula and two professional references to info@hivma.org. Additionally, please ask your mentor to complete the sponsor registration form on our website. The deadline for all application materials has been extended to Friday, February 12, 2021.

Question Title

* 1. General Information

Question Title

* 2. Contact Information

Question Title

* 3. Email

Question Title

* 5. Race/Ethnicity (optional):

Special consideration will be given to Black/African American and Hispanic/Latin candidates because they are disproportionately affected by HIV and are under-represented in the HIV medical workforce.

Question Title

* 6. Gender (optional):

Question Title

* 7. Are you legally authorized to work in the U.S.?

Question Title

* 8. Are you currently pursuing or receiving Fellowship funding from other sources?

Question Title

* 10. In 500 words or less, please discuss your career goals and objectives as they relate to the care of people with HIV. Discuss prior training and how it relates to an interest in expanding education and training in HIV medicine. Discuss your professional goals as they relate to the care of people with HIV. Please be as specific as possible and focus on your professional experience and goals.

Question Title

* 11. Please indicate the patient populations that you are Interested in working with:

Question Title

* 13. Sponsorship Information (*If you selected 'No', you must contact us before submitting your application to be matched with a sponsor in your desired area.)

Question Title

* 15. How did you learn about the HIVMA Clinical Fellowship Program?

T