Physician / Non-Physician
PRECEPTOR APPLICATION

Asterisk indicates the information is required; no asterisk indicates the information would be helpful but is not required.
Preceptor Application
Preceptor Type *
Physician
Non-Physician
Resident
Name*
First Middle Last
Date Of Birth Gender
Male Female
Degree * AOA Number AMA Number
Board Certified? * Certification Date Certified By
Yes No

Board Eligible?

Primary Practice Information
Primary Office Name *
Primary Office Address *
Street Address
Address 2
City State Zipcode
Office Phone Office Fax
Cell Phone Email *

Affiliated Hospital Information
1st Affiliated Hospital Name if applicable 2nd Affiliated Hospital Name if applicable 3rd Affiliated Hospital Name if applicable
Specialty:* Subspecialty:
Medical License Number State Issued *

Point of Contact Information

Please provide the point of contact for clinical rotations (office mgr. or other)
First Last
Title Email
Phone Fax

CV and Malpractice Insurance Release *

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.
First * Last *
Date *

Academic Appointments
Do you hold any other academic appointments? * 1st Academic Appointment         (If Yes Please List)
YesNo
2nd Academic Appointment         (if applicable) 3rd Academic Appointment         (if applicable)

Additional Required Information
License Information *
Has your license to practice medicine in any jurisdiction ever been refused, limited, suspended, or revoked?
Yes
No
Hospital Privileges Information *
Have your privileges on any hospital staff ever been refused, limited, suspended, revoked, diminish or non-renewed?
Yes
No
DEA registration Information *
Has your DEA registration or State controlled substance certificate ever been limited or suspended or revoked?
Yes
No
Conviction Information *
Have you ever been convicted of a misdemeanor or a felony (other than a minor traffic violation)?
Yes
No

Explanation
If you answered YES to any of the questions above, please provide a written explanation below.

Optional Information

(Requested by accrediting bodies)

Race/Ethnicity
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.

Preceptor Certification Signature *
First * Last *
Date *


Creator: Jerry Gaber
Updated/Created:  Nov 07, 2018 / April 1, 2017