International Application
Courses for Public Health Professionals

Rollins School of Public Health of Emory University

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International Application
This information is only for those applying for the International Course in Applied Epidemiology,
all others should use the domestic application.

Use the on-line application below:
   or
download a pdf version of the international application.

Click to download domestic application as PDF Click here to download an Adobe Acrobat (.pdf) version of the international application.

Download the international application, complete and then print.
You can mail or Fax your completed application to:

Pia Valeriano, BSC, MBA
Associate Director, Cont. Medical Education/Special Programs
Rollins School of Public Health of Emory University
1518 Clifton Road, NE, CNR Bldg., Room 7038
Atlanta, Georgia 30322 USA
Fax: 404-727-4590

The FREE Adobe Acrobat Reader is available at: http://www.adobe.com/products/acrobat/readstep2.html

Online International Application

  First Name:     Last Name (Surname):
Gender:
Birthdate: Month Day Year
Do you have a USA Visa?   Yes   No

Complete Home Address:

Work Telephone:  
Work Fax:

Email Address (Important):


Supervisor's Name:
Supervisor's Phone:
Supervisor's Email:

Employer (Company):
Division/Department:
Your Title/Position:
Complete Work Address:

Education (Degrees and Dates):

Previous Experience in Health, Public Health, Epidemiology,
Statistics or Laboratory Science:

Current Responsibilities:

Please indicate how your training will be financed:
  Self
  Employer
  Other Organization
If you choose Other Organization:

Name of Organization:
Address:
Contact Person:
Contact's Phone:
  Contact's Fax:
Contact Person's Email:

   

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Rollins School of Public Health of Emory University
Co-sponsored by:
The Rollins School of Public Health of Emory University (RSPH)
Hubert Department of Global Health
and The Centers for Disease Control and Prevention (CDC)
Office of Epidemiology, Surveillance and Laboratory Services
CDC Office of Workforce and Career Development