Easy Spanish for Health Care Professionals
To determine eligibility for an AETC scholarship, the following form must be filled out. * required fields
name *: degree(s): title:
employer: address 1*: address 2: city*: state*: zipcode*: (For the address above, please indicated home or office) Home Office daytime phone*: home phone: e-mail address*: number of HIV/AIDS patients seen weekly*: or number of HIV/AIDS patients seen monthly*: description of the services provided: Florida license number *: