Baylor College of Medicine Physician Exchange Program
Fellowship for Short-Term Training of
Mexican Physicians at Baylor College of Medicine

Application Form

Six copies of each application, comprising this form and attachments, must be submitted for consideration. The Physician Exchange Program is part of the five-year Bristol-Myers Squibb Mexico HIV/AIDS Initiative. Applications will be considered as they are received. The Program Steering Committee and Director will review applications, and communicate a decision to each applicant.

Submit applications to:

Mark W. Kline, M.D.
Professor of Pediatrics
Baylor College of Medicine
St., MC1-4000
Houston, Texas, USA 77030-7239

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Applicant Name

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Name of Affiliated Institution (If Applicable)

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Street Address City

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State ZIP Country

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Telephone Fax E-Mail

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Signature and Date

Please provide the information requested on the next page and attach it to this form.

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?

Please attach the following information.

• Curriculum vitae
• Two letters of recommendation (see attachment)

Thank you.

Baylor College of Medicine Physician Exchange Program
Fellowship for Short-Term Training of
Mexcian Physicians at Baylor College of Medicine

Statement of Recommendation

(To be completed by the applicant’s supervisor or institution representative)

Please send completed statements to:

Mark W. Kline, M.D.
Professor of Pediatrics
Baylor College of Medicine
St., MC1-4000
Houston, Texas, USA 77030-7239

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Name

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Title

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Professional Discipline and Degrees

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Place of Employment

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Street Address City

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State/Province Postal Code/ZIP Country

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Work Telephone Fax E-Mail

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Home Telephone Fax E-Mail

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Name of Applicant You Are Recommending and Date

Please provide the information requested below and attach it to this form.

Please provide the following information using your institution’s letterhead stationery:

Based upon 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.

Thank you.