"*" indicates required fields Name* Select if applicable.Dr.Mr.Mrs.Ms. Title First name Middle name (or initial) Last name Provider type:*Please select.PhysicianPhysician AssistantAdvanced Practice NurseMental Health ProviderOther Allied Health ProfessionalPlease list your supervising physician:* Gender*Please select.MaleFemaleOther/Prefer not to discloseDate of Birth* MM slash DD slash YYYY Cell phone:Office phone:*Email address:* Fax number:To see information on RVU's Title IX policy, please click here:*Title IX I attest to having read and understand RVU’s Title IX Policy and Conflicts of Interest & Student Confidentiality in the Clinical Setting Policy. PRACTICEPractice name:* Practice type:* Outpatient Inpatient Surgical center Long term care facility/Rehab Emergency/Urgent care Teaching residents at practice site Other If other, please explain:*Practice address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code List the hospital(s) used in your clinical practice. (Please type "N/A" if none.) EDUCATIONAL INFORMATIONProfessional School:* Grad year:* Credentials:*i.e. - DO, MD, PA, ANP, MS, MPAS, MSN, PhD, etc. Residency (if applicable): Grad year: Specialty:* LICENSURELicense number:* HiddenLicense UploadMax. file size: 512 MB.State:* Licensure type:*e.g. Medical, PA, ANP Licensure expiration date:* MM slash DD slash YYYY CERTIFICATION:Are you board certified?* Board certified Board eligible Not certified Certification type (ABFM, FACOFP, NCCPA, etc.):* Certification number: Date first certified:* MM slash DD slash YYYY Is this a lifetime certification?* Yes No Certification expiration date:* MM slash DD slash YYYY Please attach your certification:*(.doc, .docx, or .pdf) Drop files here or Select files Accepted file types: doc, docx, pdf, Max. file size: 10 MB. Please explain how you are board eligible:*Please explain your reasoning for application without board certification:*Students accepted for rotation:* Third-year medical students Fourth-year medical students Physician assistant students Would you like an adjunct clinical faculty rank appointment from Rocky Vista University?* Yes No Please attach your CV:*(.doc, .docx, .pdf) Drop files here or Select files Accepted file types: doc, docx, pdf, Max. file size: 10 MB. Please attach your certificate of insurance (Malpractice COI):(.doc, .docx, .pdf) Drop files here or Select files Accepted file types: doc, docx, pdf, Max. file size: 10 MB. COI expiration date: MM slash DD slash YYYY Would you like online access to the Frank Ritchel Ames Memorial Library at Rocky Vista University?* Yes No Name of the RVU contact with whom you are working:*Please select.Amie KoenigAmy HumphriesAmy MaupinAngela HallAshlee BishopChristy Hardt (PA)Dr. Dan ChappellDr. George IssaDr. Joel DickermanDr. John NicholsDr. Johnny ChengDr. Josh ToldDr. Mark LeeDr. Megan HaldyDr. Ryan SpilmanDr. Tom ToldJaime CovingtonJennifer WatsonMichelle KochMorgan BaileyKristen Hunter (PA)Kristin Kelley-GomezSarah NordgranVanessa LundOtherPlease specify:* If this form is being submitted on behalf of the preceptor, who is submitting this form?*Note: Students may not enter submission on behalf of the preceptor.* Your e-mail address, if you are submitting on behalf of the preceptor: If you have any questions, please contact Preceptor Staff Services in the Clinical Education Department at shampton@rvu.edu.