• Please always use your Burrell College of Osteopathic Medicine Email (ex firstname.lastname@mybcom.org )
  • Date Format: MM slash DD slash YYYY
  • Requested Dates for Rotation:
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Rotation Site / Institution

  • Office Manager / Site Coordinator

  • Note: Student will be given some responsibility to assist in paperwork necessary for credentialing of their preceptors and establishing affiliation agreements. Preceptors must be credentialed and both the Institution and Burrell College of Osteopathic Medicine must execute agreements no less than ninety (90) days prior to the anticipated rotation start date, or the rotation may be cancelled.
  • Drop files here or
    Accepted file types: jpg, png, gif, pdf, doc, docx, jpeg, jpg, jpeg, png, pdf, doc, docx.
  • Date Format: MM slash DD slash YYYY
  • Submission of this request form does not constitute approval.