Application

This is not a test; there is no wrong answer. Kindly answer each question to the best of your ability to help us learn more about you and your interest in this training program.

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* 1. Name

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* 2. Organization, affiliate, if any

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* 3. Address

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* 4. Select the region where you live.

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* 5. Cell  phone:

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* 6. Email:

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* 7. What year were you diagnosed with HIV?

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* 8. Current gender identity

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* 9. Race

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* 10. Age group

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* 11. Transmission risk category

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* 12. Are you currently employed?

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* 13. If yes to #12, answer this question, if no, go to question #14.

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* 14. What 3 priority issues affecting PLWH concern you the most?

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* 15. What communities do you most identify with?

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* 16. Which social media do you interact with the most?

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* 17. In 300 words or less, tell us why you want to be part of this program.

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* 18. In 300 words of less, share your leadership experiences as a person of color living with HIV.

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* 19. In 300 words or less, why should the Pipeline BLOC Project select you to be part of the program?

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