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 Does this practice offer TeleMedicine?* Yes No 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:* 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:*Have you had any prior experience precepting/teaching medical students, residents, fellows, nurses, nurse practioners, physician assistants, or EMTs?* Yes No 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.Morgan BaileyAshlee BishopDr. Dan ChappellDr. Johnny ChengJaime CovingtonDr. Joel DickermanDr. Megan HaldyAngela HallChristy Hardt (PA)Amy HumphriesKristen Hunter (PA)Dr. George IssaKristin Kelley-GomezMichelle KochAmie KoenigDr. Mark LeeVanessa LundAmy MaupinDr. John NicholsSarah NordgranDr. Ryan SpilmanDr. Tom ToldJennifer WatsonDr. Josh ToldOtherPlease specify:* If this form is being submitted on behalf of the preceptor, who is submitting this form? 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.