2021 HIVMA Clinical Fellowship Application

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.

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* 1. General Information

First Name

Middle Initials

Last Name

Degree(s)

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* 2. Contact Information

Street Address

Address Line 2

City

State

Zip

Phone

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* 3. Email

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* 4. Training Status/Practice Experience

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* 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.

American Indian

Asian

Black/African American

Hispanic/Latino

Native Hawaiian/Pacific Islander

White/Caucasian

Other (please specify)

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* 6. Gender (optional):

Female

Male

Transgender Female/Trans Woman

Transgender Male/Trans Man

Non-Binary/Genderq

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

Yes

Yes, but my work visa expires on

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

Yes

If ‘Yes’, please list other sources:

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* 9. Are you applying for a full-time or half-time award?

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* 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.

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

Adults

Adolescents

Children

MSM

Women

Transgender

Other (please specify)

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* 12. Have you contacted a sponsor?

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* 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.)

Sponsor's Name

Sponsor's Phone

Sponsor's E-mail

Sponsoring Institution

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* 14. Is your sponsoring institution aware that you are applying for this fellowship? (*Important! You must contact your institution’s administrators immediately to make them aware that you will be applying for this fellowship. For more information about this, please contact us.)

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

Google or other search engine

HIVMA member

Training Program Director

Other (please specify)

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* 1. General Information

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* 2. Contact Information

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* 3. Email

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* 4. Training Status/Practice Experience

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* 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.

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* 6. Gender (optional):

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

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

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* 9. Are you applying for a full-time or half-time award?

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

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* 12. Have you contacted a sponsor?

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* 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.)

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* 14. Is your sponsoring institution aware that you are applying for this fellowship? (*Important! You must contact your institution’s administrators immediately to make them aware that you will be applying for this fellowship. For more information about this, please contact us.)

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

* 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.