Preceptorship/Internship Form

First Name *

Last Name *

Address *

Address 2

City *

State *

Country *

Zip Code *

Day Phone *

Email Address *

College/University

Program of Study

Program Length

Clinical Hours Needed

Semester Start

Are you currently under investigation for or have you ever been subject to a disciplinary action at any college, university, or other training program in connection with misconduct or violation of an honor code which investigation could have resulted or did result in disqualification, suspension, dismissal or other sanctions?

Yes

No

If Yes, Please Explain

Have you ever been convicted or pleaded no contest to any offense, misdemeanor, or felony in any state, the United States, or a foreign country (excluding violations in traffic laws resulting in fines of $200 or less)?

Yes

No

If Yes, Please Explain

Please disclose and explain any suspensions, restrictions or revocations on your ability to practice medicine in any jurisdiction:

Please describe your medical licensure status, including any states or countries in which you have been license:

What else should we know about your preceptor/clinical/intern needs?

Yes

No