NH GH Program - Application for international visitors

Application for Nuvance Health Global Health Academy visitors

Thank you for your interest in visiting the Nuvance Health Global Health Program. Please take a few minutes to complete the application form provided below. IMPORTANT: Prior to initiating this application, please make sure to have the following documents available and saved on your computer and ready to upload: 1) A color copy of your passport (photo page); 2) Your current curriculum vitae. Thank you!
Full Name (as shown in passport)*

PrefixFirst NameMiddle NameLast Name
Gender*

MaleFemalePrefer not to answer
Date of Birth (as shown in passport)*

DayMonthYear
Citizenship*
Do you have a passport valid for international travel? Please note that, in most cases, your passport needs to be valid for at least six months after your intended return date.*

YesNo
Cell Phone Number*

International codePhone Number
E-Mail address*

Confirmation Email
Which Institution are you affiliated with?*
Please indicate the proposed dates of your visit.*
Please choose a purpose of your visit*

Business visit (Meeting with leadership, Annual Day, Discuss MoU etc.)Capacity building (Medical Education/Clinical Observership)
Is this your first visit to the Nuvance Health GH Academy?

YesNo

Please indicate your current academic rank/position/training at the Institution*

FacultyFellow in trainingResidentOther
Please indicate your field of residency/fellowship training*
e.g. Internal Medicine, Cardiology
Please indicate in which field/specialization you would like to be trained in?*
Do you have a medical insurance policy to cover medical expenses during your travel and stay in the United States?*

YesNo
Please include a paragraph describing your objectives for the upcoming visit to the US. Please specify your specific interests, areas of focus, the topics/skills you are particularly interested in learning about, and any research interests, if applicable. Feel free to include any additional information you find relevant.*

Attach Following Documents
Please upload a color scan of the front page of your passport (PDF or JPEG files are acceptable)*

Upload a File
File size limit 2 Mb Cancelof
If you already have a US visa, please upload a color scan of the passport page with your visa (PDF or JPEG files are acceptable)

Upload a File
File size limit 2 Mb Cancelof
Please upload your most current Curriculum Vitae (CV) (DOC, DOCX, PDF, or JPEG files are acceptable)*

Upload a File
File size limit 1 Mb Cancelof
Please upload a brief motivation letter (maximum 1 page) outlining your objectives for the upcoming visit to the U.S. Specify your interests, areas of focus, topics or skills you are particularly eager to learn about, and any relevant research interests, if applicable. Feel free to include any additional information you consider relevant. (DOC, DOCX, PDF files are acceptable)*

Upload a File
File size limit 1 Mb Cancelof
Please upload a color professional photo (headshot) (PDF or JPEG files are acceptable)*

Upload a File
File size limit 2 Mb Cancelof
Sign and Submit Application Form
By signing this form, I confirm that the information contained herein is correct to the best of my knowledge.*
Please type your full legal name here
Please tick the box below*
Should be Empty:

Application for Nuvance Health Global Health Academy visitors