Application Form for: Exchange scholarships to Argentina 2014

·  Before completing your application please refer to the Gilead Exchange Scholarships in collaboration with
BHIVA Guidance Notes for Exchange scholarships to Argentina 2014
·  All sections of the Application Form must be completed or indicate ‘not applicable’ where appropriate
·  Please email an electronic copy of your application to
·  Please also post an original signed copy of your application to:
BHIVA Secretariat | Mediscript Ltd | 1 Mountview Court | 310 Friern Barnet Lane | London N20 0LD
·  BHIVA must receive both the electronic and paper copies of your application form by the submission deadline of 1700 GMT Friday 18 July 2014 (Any applications received after this date will not be accepted)
Section 1: Personal Details
Title: / First Name(s):
Surname:
Section 2: Current Employment details / Section 3: Address for correspondence
Job title
Department
Institution / organisation
Telephone
Fax
Email
Category: / Consultant (less than 5 years)
Non-consultant doctor (Specialist Registrar)
Section 3: Language skills (not essential)
Please tick the box which most accurately describes your fluency in Spanish
FLUENT Able to communicate effectively using technical and scientific language
CONFIDENT Able to speak the language to a high standard without feeling intimidated
COMFORTABLE Able to lead casual conversations
AVERAGE Able to express ideas and follow conversations
BASIC Able to recall a few key words or phrases
NONE Unable to speak any Spanish
Section 4: Previous employment
Please list in reverse chronological order your past 7 years employment history
Years (From / to) / Job title / Institution / Organisation
/
/
/
/
Section 5: Qualifications
Are you currently studying for a relevant professional qualification? If so, please provide details
Please provide details of all other professional qualifications held
Section 6: Awards
Please provide details of any awards that you have received during your career (e.g. fellowships / bursaries / prizes)and, in addition, please provide any other achievements / activities / voluntary positions held that are relevant to this application (e.g. journal editor / involvement in working group)
Section 7: Membership
Please provide details of all relevant memberships
Section 8: Areas of expertise
Please list your three main areas of expertise and interest
1. 
2. 
3. 
Section 9: Exchange Programme Information
Have you taken part in an exchange programme in South America before? / YES / NO
If yes, please indicate when
Pre-2009 / 2009 / 2010 / 2011 / 2012 / 2013
Section 10: Supporting statement
Please tell us, in no more than 500 words why you would like to participate in an exchange programme in Argentina in November 2014.
From colleague (optional):
Please tell us in no more than 250 words why you would support the applicants participation in an exchange programme in Argentina in November 2014.
Details of colleague providing the supporting statement
Full name:
Job title:
Institution / organisation
Relationship to applicant
Section 11: Approval from Department Clinical Director
It is essential that the Clinical Director of your department, or the Clinical Director of an HIV department at a large hospital centre nearby to you, support your application and agrees for one scholar from Argentina to attend ID clinics at the Centre from 29 September-10 October 2014. If the centre is unable to support the scholar for the full period please indicate this below. Funding would be available to support accommodation, living expenses and travel costs for the scholar whilst in the UK.
From Clinical Director
By signing below I agree to support the application of the aforementioned candidate to take part in an exchange programme in Argentina in November 2014. In addition, I agree to support and make arrangements for one scholar from Argentina to attend ID clinics in the below Centre from 29 September-10 October 2014.
Name of Hospital:
If your centre is unable to support the placement of the scholar from Argentina for the full period please indicate this here:
Details of Clinical Director providing support
Full name:
Job title:
Institution / organisation
Relationship to applicant
Section 12: Signatures and Agreements
I have read the Gilead Exchange Scholarships in collaboration with BHIVA Guidance Notes for Exchange scholarships to Argentina 2014 and have noted the terms and conditions, including those for cancellation, and agree to abide by these rules should the above application be successful
I have not previously been awarded a BHIVA Exchange Scholarship in 2010-2014
Applicants name / Signature / Date
Supporting colleague’s name / Signature / Date

Administrators: Mediscript Ltd.

1 Mountview Court, 310 Friern Barnet Lane, London N20 0LD

Tel: 020 8369 5380 Fax: 020 8446 9204 email: