BUCOM Preceptor Application

Thank you for your interest in a preceptor position with Baptist Health Sciences University College of Osteopathic Medicine (Proposed). 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.

Personal Information

Last Name:

First Name:

Middle Name:

Date of Birth:

Preferred email address:

Home Phone:

Office Phone:

Cell Phone:

Address

City/Town

State/Province

ZIP/Postal Code

Office/Practice manager:

Contact Phone Number:

Degree (DO vs MD)

Doctor of Osteopathic Medicine

Doctor of Medicine

Specialty

Primary Board Certification:

Primary Board Certification Expiration Date:

Certifying body: (AOA vs ABMS)

American Osteopathic Association (AOA)

American Board of Medical Specialties (ABMS)

Medical Licenses

Medical Licenses Number:

State/Province

Expiration Date of Licenses:

Medical Licenses Number:

State/Province

Expiration Date of Licenses:

Medical Licenses Number:

State/Province

Expiration Date of Licenses:

NPI # ( National Provider Identification Number)

Hospital Affiliation:

Curriculum Vitae (CV)

Attach current CV or fill out abbreviated CV form

Abbreviated CV form

Attach current Curriculum Vitae

One file only.
64 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.