Sponsor Registration Form You must be logged in to submit this form. If you are logged in and still cannot post, make sure "Do not track" in your browser settings is disabled. Institution Street Address Address 2 City Zip Code Contact Name Phone Email Number of HIV Patients(Demographics below) Female Asian Black/African-American Hispanic or Latin Native American or Alaskan Native White/Caucasian Other HIV Sub-populations of Interest Men Who Have Sex With Men(MSM) Adolescents Pregnant Women Children Approximately how many HIV Patients might the clinical fellow managing? How many fellows can your institution support? Assuming funding from HIVMA to cover salary/benefits, will your institution be able to offer the candidate an employees benefits package? Yes No Will fellows have access to other HIV medical education opportunities such as lectures, case studies, ect? Yes No Does your institution have links to other clinics/programs at which candidates may spend up to 2 months of their fellowship? Yes No How many HIV sub specialists are on staff? Obstetrics/Gynecology Gastroenterology Hematology-Oncology Does your institution already have an HIV Training Program? Yes No Is this program part of an Infectious Diseases training program? Yes No If no, please describe. Has the fellowship been approved by your institution? Yes No Multiple or single choice Yes No What is the full name of the proposed member for this program (if known)? What is his/her title? Word verification Refresh captcha Submit
