INMED - Institute for International Medicine

Institute for International Medicine
Equipping healthcare professionals to serve the forgotten

Read Student Blogs

Join Our Facebook Group

Follow Us On Twitter

View Our Photos

Watch Our Videos

INMED International HIV Medicine Certificate Application

Instructions

Please allow 40-60 minutes to complete this application process. Currently, it is not possible to save your unfinished application and then later return. Be prepared to submit a personal photo and a $50 application fee, payable via credit or debit card, or by personal check.

Please complete all fields. Some questions call for descriptive answers. It is to your advantage to provide as full a response as possible.

We highly recommend you save a personal copy of your application in case it is not received by INMED. Print a hard copy of this completed page, and/or save your responses in a Word document or web page.

Step 1 of 4

Date of application: 2/4/2012

General Information

Today's date:
First name:
Last name:
Age:
E-mail Address:
Alternate E-mail Address:
Home phone:
Mobile phone:
Home Mailing Address Line 1:
Home Mailing Address Line 2:
City:
State
Zip Code:
Country:
Academic Degree:
Specialty/Title:
Occupation:
How did you first hear about INMED?:
Please Describe How You Heard:
Marital status:
Birth date:
Sex:
Country of Citizenship:

Academic Institution Complete this section if you are currently enrolled as a student, resident or fellow.

Year of Training:
Core Rotations & Electives that will be completed prior to International Elective (if applicable):
Academic Institution name:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State:
Zip Code:
School/Residency phone:
Academic Coordinator's First Name:
Academic Coordinator's Last Name:
Coordinator's e-mail:
Coordinator's phone:

Emergency Contact Information

Emergency Contact's First Name:
Emergency Contact's Last Name:
Relationship:
E-mail Address:
Home phone:
Mobile phone:
Mailing Address Line 1:
Mailing Address Line 2:
City:
State:
Zip Code:

Elective Schedule

Electives are offered year round, and generally must be at least 4 weeks duration. Please list in order of preference 1-3 the dates you are available for this elective:

1. Departing Date Returning Date

2. Departing Date Returning Date

3. Departing Date Returning Date

Do you have any friends you wish to be placed with? If so please list their name(s):
In an effort to respect cultural norms of host nations, INMED does not send students
who are dating to the same training site simultaneously.

Institute for International Medicine is a Missouri registered, 501c(3) recognized, non-profit corporation.
INMED is a registered trademark of the Institute for International Medicine.
All INMED content is copyrighted 2012. All rights reserved.
Click here to read our Privacy Policy