Healthcare Leadership Training Program Application Form

Healthcare Leadership Training Program Application Form
Today's date*

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Applicant Information
Full Name*

First NameLast Name
Gender

FemaleMaleDecline to State
Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail address: *
Phone Number*

Area CodePhone Number
The Program requires that those admitted enter the US under their own, B (Visitor) visa. Please indicate your status:

I currently have a valid, B (Visitor/Tourism) visa to the United StatesI will apply for a B visitor visa if/when I am offered admissions into the ProgramI am a US citizen (do not need a visa)I am a dual citizen (USA/home country of residence) and do not need a visaI do not have a US visa
Have you visited the United States before?

YesNo
What method of transportation would you plan to use while in San Diego during the Program?

Personal Vehicle (driving your own car/CA Driver's License)Public Transportation (city bus, shuttle, trolley, etc. )Ride-Sharing Transportation (i.e. Uber, Lyft, Taxi Cab, etc.)Other
Educational Background
Name of Medical/Pharmacy/Nursing and/or Professional School*
Country of medical school location
Area of Specialty/ Discipline/Major*
Graduation (Or, Expected) Date*

MonthDayYear
Are you affiliated with or employed by any institution in your home country? (i.e. University, hospital, medical city, ministry, military/defense, etc?)*
If YES, please specify:
Availability
Preference #1*
Year*
Preference #2
Year
Documentation
Upload CV*

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Upload Transcripts:*

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Scanned Copy of Your Passport's photo page*

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Other attachments (Valid Licenses, Certificates, Awards, Supporting Letters, etc)

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Please describe the anticipated benefits of the Healthcare Leadership Program in helping you achieve your career goals*
How did you learn about this program?*
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Healthcare Leadership Training Program Application Form

Applicant Information

Educational Background

Availability

Documentation