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.

* 1. Name

* 2. Organization, affiliate, if any

* 3. Address

* 5. Cell  phone:

* 6. Email:

* 7. What year were you diagnosed with HIV?

* 12. Are you currently employed?

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

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

* 15. What communities do you most identify with?

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

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

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