Non-Physician Preceptor Application - Copy 1

  • Section 1:

  • Primary Office

  • Hospital Affiliations

    Enter all Hospital Affiliations
  • Additional Hospital Afilliation

    if applicable
  • Additional Hospital Afilliation

    if applicable
  • Point of Contact

    Please provide the point of contact for clinical rotations (office mgr. or other)
  • Additional Required Information

  • I authorize the hospital or my primary office staff to release a copy of my CV, License, Board Certification and Malpractice Insurance.
  • Academic Appointment:

  • Do you hold any other academic appointments?
  • If yes Please List
  • if applicable
  • if applicable
  • Has your license to practice medicine in any jurisdiction ever been refused, limited, suspended, or revoked?
  • Have your privileges on any hospital staff ever been refused, limited, suspended, revoked, diminish or non-renewed?
  • Has your DEA registration or State controlled substance certificate ever been limited or suspended or revoked?
  • Have you ever been convicted of a misdemeanor or a felony (other than a minor traffic violation)?
  • If you answered YES to any of the questions above, please provide a written explanation below.
  • Optional Information

    (Requested by accrediting bodies)
  • Consent

  • I hereby certify that the information on this application and all other information that I receive otherwise provided is true and correct. I understand that any misrepresentation or omission will be sufficient cause for cancellation of this application or removal from the clinical faculty roster.

    I agree to notify Burrell College of Osteopathic Medicine credentialing department of any changes to my license and any other information included on this form.

    I have read and agree to abide by the American Osteopathic Association Code of Ethics.

    I represent and warrant that I have read and fully understand the foregoing, and I seek a Clinical Preceptor appointment under these terms.

    I warrant that all of the information that I have provided and the responses that I have given are correct and complete to the best of my knowledge and belief.
  • Your electronic signature below indicates your consent to the statement above.