PRECEPTOR APPLICATION
Asterisk indicates the information is required; no asterisk indicates the information would be helpful but is not required.
Preceptor / Resident Application
Preceptor Type *
Physician
Resident
Contract-Fac-Preceptor
Name*
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
Specialty:*
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)
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

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)

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 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