MIDS Application

First Name*

Last Name*

Degree*

Are you currently in an ID fellowship?*

Select or enter value

Hospital or University Affiliation*

Fellow Graduation Date*

Director of Training Program

Director of Training Program's Email

Field of Training (If other then ID)

Contact Information

Email Address*

Cell Phone Number*

Address*

City, State*

Zip*

Division Chief/Department Chair

Division Chief/Department Chair's Email

Are you infectious disease board eligible?*

Select or enter value

Are you board certified?*

Select or enter value

Academic/University

Community - Teaching

Community - Non-Teaching

Private Practice

Clinical Infectious Diseases

Public Health/Epidemiology

Clinical Microbiology

Research

Clinical Pharmacy

Other

IDSA

MSMS

OSMS

MDHHS

Subspecialty/Practice Focus (Optional)

Example: HIV Medicine, Transplant Infections, Geriatric Infectious Disease

Research Interest (Optional)

Two MIDS members who support this application*

CV Upload*

Drag and drop files here or

Send me a copy of my responses