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  • General Information

     First Name MI  Last Name
         
         
    Highest Degree Completed:   
       
    Year of Residency:    
       
    I am applying for the: 
                         

     
     
    Street Address   
    Address Line 2  
    City  
    State  
    Zip  
    Phone   
    E-mail   
     
    Are you legally authorized to work in the U.S.?
                                  

     

    Fellowship Funding Sources

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

     
    If ‘Yes’, please list other sources:  

    Personal Statement & Interests

    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.

     

    Subpopulations of interest
    (check all that apply):
     

    Sponsorship Information

    Have you contacted a sponsor?
                                                     

     
     

    *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  
    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. 

    How did you learn about the HIVMA Minority Clinical Fellowship Program?
                                      

     

     

    If you do not receive a confirmation message or encounter an error please email us at info@hivma.org.

     

 

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