2020 HIVMA Clinical Fellowship Application

This form is to submit general information and a personal statement for your application. Please also email your CV and training curricula to info@hivma.org. Additionally, please ask your mentor to complete the sponsor registration form on our website. The deadline for all application materials is January 21, 2020.

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* 1. General Information

First Name

Middle Initials

Last Name

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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

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* 5. Ethnicity: Special consideration will be given for African American and Latino candidates.* Let us know if you identify as the following:

*These race/ethnicities were identified because they are disproportionately affected by HIV/AIDS and are under-represented in the HIV medical workforce.

Black/African American

Hispanic/Latino

Neither

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

Yes

Yes, but my work visa expires on

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

Yes

If ‘Yes’, please list other sources:

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* 8. In 500 words or less, please discuss your career goals and objectives as they relate to the care of people with HIV/AIDS. Discuss prior training and how it relates to an interest in expanding education and training in HIV medicine. Discuss how this may translate into a professional career that includes the element of caring for HIV infected patients. Please be as specific as possible and focus on your professional experience and goals.

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* 9. Interest

Adolescents

Children

MSM

Pregnant Women

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* 10. Have you contacted a sponsor?

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* 11. 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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* 12. 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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* 13. 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

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* 5. Ethnicity: Special consideration will be given for African American and Latino candidates.* Let us know if you identify as the following:*These race/ethnicities were identified because they are disproportionately affected by HIV/AIDS and are under-represented in the HIV medical workforce.

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

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

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* 9. Interest

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* 10. Have you contacted a sponsor?

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* 11. 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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* 12. 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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* 13. How did you learn about the HIVMA Clinical Fellowship Program?

* 5. Ethnicity: Special consideration will be given for African American and Latino candidates.* Let us know if you identify as the following:

*These race/ethnicities were identified because they are disproportionately affected by HIV/AIDS and are under-represented in the HIV medical workforce.