Online Application Form

PEPFAR Fellowship Programme APPLICATION FORM FOR PLACEMENT AS A FELLOW WITH PEPFAR PARTNERS IN SOUTH AFRICA


PLEASE NOTE: To qualify for the PEPFAR Fellowship Programme, candidates must:

1. Have their masters qualification or be in final year of studies with one exception to HMIS Applicants who can apply at level of either BCom or Masters in Medical or Health Informatics
2. Be a South African Citizen or have permanent resident status with an official Identity Book. Should you be a non South African candidate, please send us your CV and Cover Letter and we will make this available to our host organizations for consideration outside our fellowship programme.
3. Once your full application has been received, your profile will be on our data base for placement consideration. Should a position correspond to your profile we will contact you, otherwise you will stay on our data base until such time.

Confidential
*Note: please ensure that your name is clearly stated on each page of the application form if it is being faxed through to us. Also ensure that "N/A" is inserted in areas that are not applicable.


PERSONAL DETAILS
Surname
Forenames / First names
Title
Date of Birth
Current Residential Address
Address Line 2
Address Line 3
Address Line 4
Current Postal Address
Address Line 2
Address Line 3
Address Line 4
Telephone number including dialing code
Home:
Work:
Cell/Mobile:
Fax:
Email address
South African Identity Document Number
Do you have a driver's license? Specify type:


LANGUAGE PROFICIENCY
LANGUAGE SPEAK READ WRITE
English


DISABILITIES
*"People with disabilities" means people who have a long term or recurring physical or mental impairment which substantially limits their prospects of entry into or advancement in employment or the performance of normal day to day tasks or functions.

Are you Disabled?    
If Yes, please state the kind of disability.


MEDICAL INFORMATION
Do you have any medical history or condition that may affect your ability to meet the requirements of the specific position that you are interested in applying for?    
If Yes, please specify


CRIMINAL RECORD
Do you or any of your dependants have a criminal record that may reasonably be thought relevant to your unfitness for this position or that may affect your insurability as a fellow employee?    
If yes, please state details and the date that it occurred.


ACADEMIC RECORD
Is your Masters Degree completed or in process of completion?    
Specify type of Masters Degree obtained/in process of completion
Name of University and Department where Masters degree was obtained / being obtained
Number of years enrolled for this masters degree
Is this the final year of your masters degree? If not, which year are you currently in?
Contact details of academic supervisor/mentor
Specify any academic sponsorship commitments which may interfere with the six-month fellowship placement
Specify all other degrees and/or diplomas obtained before and /or after Masters degree


FELLOWSHIP PREFERENCES
*These details will help us to place you in a fellow position which is most suitable to you and which is mutually beneficial to both you and the specific PEPFAR placement partner.
Do you have a specific province in which you would like to be placed?
Is there a specific region in the province/s you prefer to be placed in?
Please note type of AIDS service organization which you prefer to be placed with
Please note preferred expertise focus area


EMPLOYMENT RECORD
Are you currently employed?    
If yes, please supply employer's name and contact details
Position Held at Present including salary scale
Describe your main duties and responsibilities
Reason for applying for a PEPFAR Fellow position
If employed, please specify how you will manage the 1 year fellowship placement with your current employer


PEPFAR FELLOWSHP PROGRAMME
Have you previously been placed as a fellow in a sponsored program?        
If YES: Specify
Why are you interested in a fellowship with PEPFAR partners/AIDS service organizations?
How did you hear about the PEPFAR Fellowship Programme?
Date you can commence with the fellowship?


REFERENCES
*Supply the names and addresses of at least two persons who are able to act as references (one reference is preferably from your most recent work environment). For each reference please also state whether they can be contacted at the time of your application. If you are known to these people under a different name (for instance your maiden name), please specify.
Current /most recent employer's name & address
Contact Person's name and position
Telephone Number and dialing code :
E-mail Address
Second Reference
Contact Person's name and position
Telephone Number and dialing code :
E-mail Address
**PLEASE INCLUDE THE FOLLOWING BY EMAILING THEM TO Fellowship@foundation.co.za
  • Updated CV/ Résumé
  • Certified Copies of Qualifications (degrees, diplomas, certificates, etc.)
  • Copy of current Masters degree registration if studies still in process
  • Certified copy of South African Identity Document or Passport (Non South Africans)
  • South African Police clearance certificate
  • Copy of Driver's License
  • Copy of annual registration with Health Professions Council of SA(HPCSA)(Health Care Professionals only)
  • Cover Letter outlining why you want to join the PEPFAR Fellowship Program South Africa and what special characteristics, skills and personal qualities you have which will contribute towards working within a HIV/AIDS service organization. This will help us best to place you with the most appropriate organization related to your skills profile.

    Please note: CV or Résumé should include the following:
  • all past work experience*
  • educational background (including all degrees and diplomas received)*
  • published works (including academic/scientific publications, popular articles, abstracts, papers and books)
  • participation in subject-related conferences and symposia*
  • memberships to professional affiliations/academic organizations*
  • awards, scholarships and grants received (name, sponsoring organization and date)
*Please include begin and end dates

DECLARATION
I hereby declare that all information furnished in this form is to the best of my knowledge true and correct. I understand that the PEPFAR Fellowship Programme Manager reserves the right to withdraw any offer of fellowship placement if the information furnished by me is inaccurate or misleading, I furthermore understand that the offer of fellowship placement is subject to satisfactory references.
       


 
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