Title: The AAF-OSI Medical Internship Program
Author: Mag. Gerda Simlinger-Bieger, AAF Vienna
Last saved by: Baskakova
Company: American Austrian Foundation

Please attach 
photo here.

Date of application:
	…………………………………………………………………………………………………………………………………………………………………………………………………….

The Alberto Vilar Medical Internship Program or
Pro Infantibus Application Form

Name:	__________________________________________________________________________
	(First)					(LAST)

Current Position:	____________________________________________________________

Hospital Employed at:	____________________________________________________________

Work Address:	____________________________________________________________________
		
____________________________________________________________________

Work Telephone:  ________________________Home Telephone:___________________________

E-mail:	___________________________________________  Fax:___________________________

Home Address:  ____________________________________________________________________

		____________________________________________________________________

		____________________________________________________________________

For placement purposes only:
German Language Skills (please circle): | FLUENT | GOOD | POOR | NONE

Name of Salzburg Medical Seminar Attended:	_______________________________________

Dates of Seminar Attended:	_____________________________________________________

Applying for (please circle one): 	       1^st                       2^nd                       3^rd                       Internship

Proposed Topic of Study for the Internship:	_______________________________________

Proposed months of Study for the Internship:	_______________________________________

Proposed Host Austrian Medical Institution:_________________________________________________

Proposed Physician-Mentor:	___________________________________________________________
				(If possible, please attach letter(s) of invitation)

Short Essay --  on a separate sheet of paper, please answer the following question:

What services at your hospital do you think can be improved and how would this internship help you achieve this?

To complete your application package, please attach the following to this application form:
•	A recent photograph (at the top right corner of this page)
•	Your current curriculum vitae (CV)
•	The short essay 
•	A letter of support from a senior faculty member who works with you