To apply for the Los Angeles County HIV Public Health Services Fellowship Program, interested candidates must submit a letter of interest – including career goals and how the fellowship would help him/her achieve those goals – their curriculum vitae, and a list of references, to: County of Los Angeles Department of Health Services Los Angeles County HIV Public Health Fellowship Program 5850 South Main Street, Room 2214 Los Angeles, California, 90003

1. COUNTY OF LOS ANGELES
DEPARTMENT OF HEALTH SERVICES
HIVPUBLIC HEALTH FELLOWSHIP
APPLICATION
CANDIDATE INFORMATION
Name (first/middle/last): MD DO
Birth Date:
Home phone/e-mail #1: Home #: E-Mail #1:
Mobile phone/e-mail #2: Mobile #: E-Mail #2:
Home Address:
Specialty: Family Medicine Internal Medicine Other
Board Eligible or
Certification:
No Yes Name of Board:
LICENSE INFORMATION
State Medical License:
License number/issuing body: Exp. date:
DEA License:
DEA certification number: Exp. date:
Attach copy of BLS card, if applicable
Driver’s License:
License number/issuing state: Exp. date:
Attach copy of BLS card, if applicable
NPI #:
Medical SCHOOL, RESIDENCY PROGRAM & AFFILLIATIONS
Medical School:
Name of School:
Address:
Graduation Date:
Residency Program:
Name of Residency Program:
Name of Residency Director:
Address and phone # and/or email:
Completion Date:
OTHER REQUIREMENTS (The listed items must be submitted along with the application)
1. Curriculum Vitae (CV)
2. 3 Professional References
3. Letter of Interest – stating your career goals and how this fellowship would help you to achieve your goals

2. LAC HIV Public Health Fellowship Application
Page 2
I hereby affirm that the information submitted in this application is true, current, correct, and complete to the best of my
knowledge and belief, and is furnished in good faith. I understand that material omissions or misrepresentations may result
in denial of proceeding with the application process. Iunderstand that completion ofthis application in no way obligates the
County of Los Angeles to afford me with staff membership or privileges. Iunderstand that candidates will be competitively
selected from a national search of residency programs,and only applicants who have demonstrated (1) a strong interest in
primary, (2) an interest in quality improvement, research, or system innovations, and (3) interest in serving in underserved
communities will be selected.
I also give representatives of the County of Los Angeles Department of Health Services permission to contact all of the
references listed on page 1 of this application.
PRINT NAME: _________________________________________________________________________
APPLICANT SIGNATURE: ___________________________________________ DATE: _____________
You may complete the application and submit requested copies on-line at www.DHSHIVpublicfellowship.gov or
you may return by email, in-person, or by fax to:
Attention: Alicia King
5850 South Main Street, Room #2214
Los Angeles, California 90003
Phone: (323) 846-4116
Fax: (323) 233-0958
E-mail: alking@dhs.lacounty.gov