Preceptor Application

  • Primary Practice Information

  • Affiliated Hospital Information

  • if applicable
  • if applicable
  • if applicable
  • Upload a copy of your CV
  • Upload a copy of your Malpractice Insurance
  • Point of Contact Information

    Please provide the point of contact for clinical rotations (office mgr. or other)
  • I authorize the hospital or my primary office staff to release a copy of my CV and Malpractice Insurance. Typing your name below indicates an electronic signature affirming the statement above.
  • 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)
  • Providing this information will assist us with surveys.
  • 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 or employment status.
  • 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 Faculty 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. Typing your name below indicates an electronic signature affirming the statement above.