Use this form to request the initiation of a clinical contract for clinical(s).  Please note that average times for the entire process of setting up a new contract can take 2-4 months or more.  Be sure to consider this limitation when deciding how soon to initiate a new contract for a particular semester.  PLAN AHEAD!!

 

If the agency for which you are requesting a contract is listed on the current affiliations list or the in-process affiliations list, you do NOT need to complete this form.

 

Contact Information
 

 

 *** Items must be completed.

***First Name

***Last Name
***Street Address / PO Box
Additional Address (if needed)
***City

***State

Other State / Province
In which country do you reside?
***Zip Code
***Telephone (xxx-xxx-xxxx):
Alternate Telephone (xxx-xxx-xxxx)
***E-mail address
***Please re-type email address to confirm
Course Information
***Program of Study:
***Course(s) for which I need this contract
       
To select more than one faculty person, hold down the CTRL key and click on the desired names.
***My course faculty is/are
***The semester in which I am planning to take this course is
***The year in which I am planning to take this course is
Agency Information
***Agency Name
***Do you currently work at the facility?
***Agency Street Address
***Agency City

***Agency State

***Agency Zip Code
***Contact Person
***Contact Person's title
***Contact Telephone (including extension if needed)
Contact FAX
***Contact E-mail address
***Please re-type Contact E-mail address to confirm
Additional Comment / Questions / Information
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