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

Board Eligible?

Primary Practice Information
Primary Office Name *
Primary Office Address *
Street Address
Address 2
City State Zipcode (5 Digets only)
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
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 (MM/DD/YYYY) *

Academic Appointments
Do you hold any other academic appointments? * 1st Academic Appointment         (If Yes Please List)
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?
Hospital Privileges Information *
Have your privileges on any hospital staff ever been refused, limited, suspended, revoked, diminish or non-renewed?
DEA registration Information *
Has your DEA registration or State controlled substance certificate ever been limited or suspended or revoked?
Conviction Information *
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

Please select the items you would be interested in as Burrell Faculty:
Research with Students? Yes No NA

Presentations for Students? Yes No NA

Lectures for 1st and 2nd year students? Yes No NA

(Requested by accrediting bodies)

Providing this information will assist us with surveys.


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 BCOM Code of Professional Conduct Policy

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 (MM/DD/YYYY) *
Please Verify your Dates before submitting they must be full dates in the following Format (MM/DD/YYYY)Improper dates will result in a "500 - Internal Server Error" and you will have to reenter all your Information.

Creator: Jerry Gaber
Updated/Created:  Oct 6, 2023 / April 1, 2017