International AIDS Education and Training InitiativePHYSICIAN EXCHANGE PROGRAM APPLICATION FORMTwelve copies of each application, comprising this form and attachments, must be submitted for consideration. The Program Steering Committee and Director will review applications and communicate a decision to each applicant.Submit applications to: Mark W. Kline, M.D.
_____________________________________________________________ Applicant Name
_____________________________________________________________ Name of Affiliated Institution
_____________________________________________________________ _____________________________________________________________ Street Address
_____________________________________________________________ City, State ZIP Country
_____________________________________________________________ Telephone Fax E-mail
_____________________________________________________________ Signature Date of Application
Note: Include your curriculum vitae and two letters of recommendation with this application. A recommendation form is available below.
1. Describe how you are involved in HIV/AIDS research, prevention, treatment, care and education. 2. Describe your future plans in HIV/AIDS research, prevention, treatment, care and education. 3. Describe how you will benefit from the knowledge and contacts you gain from the Physician Exchange Program. 4. Describe how and to whom you will disseminate the knowledge gained from the Physician Exchange Program. 5. Why are you uniquely deserving to be part of the Physician Exchange Program? International AIDS Education and Training InitiativePHYSICIAN EXCHANGE PROGRAM STATEMENT OF RECOMMENDATION(Recommendations should be completed by your supervisor or institution representative.)_____________________________________________________________ Name _____________________________________________________________ Job Title _____________________________________________________________ Professional Discipline and Degrees _____________________________________________________________ Place of Employment _____________________________________________________________ _____________________________________________________________ Street Address
_____________________________________________________________ City, State ZIP Country
_____________________________________________________________ Work Telephone Fax E-mail
_____________________________________________________________ Home Telephone
_____________________________________________________________ Name of Applicant you are recommending
Please provide the following information using your institution’s letterhead stationery. Based on the applicant’s past and current involvement in HIV activities, especially as these pertain to epidemiology, diagnosis, prevention, treatment, and education of HIV-infected women and children, please explain why the applicant would benefit from this Physician Exchange Program and how he/she would effectively disseminate the information gained from this program. Please sign and date your letter.
Please send completed statement to: Mark W. Kline, M.D. |