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
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