BUCOM Preceptor Application

Thank you for your interest in a preceptor position with Baptist Health Sciences University College of Osteopathic Medicine. Please fill out and submit the form below and attach your current CV. If you do not have a CV, you may fill out the abbreviated CV form (link). After verification of your credentials, the Senior Associate Dean for Clinical Affairs will review your application. If approved, you will receive an appointment letter and the BUCOM preceptor handbook.

Preceptor Contact Information

First Name:

Middle Name:

Last Name:

Credentials (DO or MD)

Doctor of Osteopathic Medicine

Doctor of Medicine

Preferred email address:

AOA or AMA ID Number for CME Credit:

Cell Phone Number:

Office Phone Number:

Site Information

Primary Practice Site Name:

Address

City/Town

State/Province

ZIP/Postal Code

Hospital Affiliation and Location: (List the one where you have privileges and where BUCOM students will rotate with you)

Physician License and Certification Information

Specialty or specialties:

Primary Board Certification: (AOA or ABMS)

American Osteopathic Association (AOA)

American Board of Medical Specialties (ABMS)

Primary Board Certification Expiration Date:

License Number:

State/Province

License Expiration Date:

License Number:

State/Province

License Expiration Date:

Office Contact Person (Office/Practice Manager or Administrative Assistant)

Contact Person's Name:

Contact Person's Email Address:

Address

City/Town

State/Province

ZIP/Postal Code

Curriculum Vitae (CV)

Attach current CV or fill out abbreviated CV form

Abbreviated CV form

Attach current Curriculum Vitae

One file only.
128 MB limit.
Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods.

I certify that I am applying for clinical faculty (non-core) credentials as a preceptor to facilitate the clinical experience and education of BUCOM students. I understand that this is not an application for employment and that receiving a faculty appointment is not an offer of employment with BCOM, BMHCC, or any BMHCC affiliated organizations. If given a faculty appointment I understand that my Name, medical license and board certification information may be provided to the Commission on Osteopathic College Accreditation and that my name may be published in the BUCOM faculty directory.