Application: Fellowship of the Association of Clinicians for the Underserved

All prospective fellows, regardless of which entry point best fits their experience, must complete the Fellowship Interest Form prior to submitting their application. This will connect you with ACU staff and guidance on the next steps.

Note: We advise all applicants to download a copy of the form and review it in full prior to submitting their answers via this form. You may also find other supporting documents below:

Question Title

* 1. Contact Info

Email Address

Confirm Email Address

First Name

Last Name

Phone Number

Certification(s)/Degree(s)

Other Fellowship(s) or Professional Designation(s)

Job Title/Role

Employer or Organization Name

State

Time at current organization (# of years)

Question Title

* 2. Organization type

Health Center (Federally Qualified or Look-Alike)

Primary Care Association (PCA)

Health Center Controlled Network (HCCN)

National Training & Technical Assistance Partner (NTTAP)

Other Healthcare Non-Profit

Other Non-Profit

Local Government

State Government

Tribal or Territory Government

Federal Government

University or College

Other (please specify)

Question Title

* 3. Please indicate your eligibility for this Fellowship: Check all that apply.

I have been an ACU Individual Member in good standing for at least one year prior to submitting this application.

I work for an organization that has been an ACU Organizational Member in good standing for at least two years prior to submitting this application

Question Title

* 4. Are you a current or a former member of the National Health Service Corps (NHSC)?

Yes, I am a current participant (service term not yet completed).

Yes, I am an alumni (service term completed).

No.