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Faculty/Contractor Information Sheet

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Faculty/Contractor Information SheetSam Turner2021-07-01T14:28:06-06:00
MM slash DD slash YYYY

Basic Information

Name:(Required)
Birthdate:(Required)
Address(Required)
Primary Email Address:(Required)
Alternate Email Address:

Demographic Information

Professional Information

Academic Information

Resume/Curriculum vitae:

Accepted file types: pdf, doc, docx, png, jpg, Max. file size: 20 MB.

In Case of Emergency – Emergency Contact:

Name:(Required)
Are you a physician?(Required)

Additional Required Questions.

License Information(Required)
Has your license to practice medicine in any jurisdiction ever been refused, limited, suspended, or revoked?
Hospital Privileges Information(Required)
Have your privileges on any hospital staff ever been refused, limited, suspended, revoked, diminish or non-renewed?
DEA registration Information(Required)
Has your DEA registration or State controlled substance certificate ever been limited or suspended or revoked?
Conviction Information(Required)
Have you ever been convicted of a misdemeanor or a felony (other than a minor traffic violation)?
If you responded YES to any of the Additional Required Questions, please explain:

I warrant that all 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.

I understand that any misrepresentation or omission will be sufficient cause for cancellation of a contract and/or removal from the faculty roster.

By submitting I hereby certify that this information provided to Burrell College is true and correct

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CONTACT OUR OFFICE

Burrell College of Osteopathic Medicine
3501 Arrowhead Dr
Las Cruces, NM 88001
Phone: 575.674–BCOM (2266)
Fax: 575.674.2267

 

Admissions: admissions@burrell.edu
Financial Aid: financialaid@burrell.edu
Human Resources: hr@burrell.edu
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The Burrell College is a private, investor owned, medical school affiliated with New Mexico State University. The Burrell College is free-standing, separately licensed and independently operated entity and not part of New Mexico State University
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