Preceptor and Facility Agreement

Student IDs begin with 5000xxxxxx or 6000xxxxxx
Some older Student IDs have the format xxx-xxxxxx.
Contact: Lindsey Heaton, 903.565.5569

Preceptor Information

* Is this Preceptor listed in Typhon?
* Gender:
* Certifying Board Name:

Facility Information

If the facility is already on the approved list, please list it as it appears there.  Also, please do not abbreviate names.
* Is this Facility affiliated with another organization or covered under a corporate umbrella? If yes, which one?
* Is this facility already on the approved list?
The Contact person IS NOT the preceptor! The Contact person is the representative at the facility who is financially responsible for signing contracts.
* Type of Facility:
* Please select the classification of this facility (most commonly used):

A copy of the agreement will be sent to you and to the preceptor at the addresses you provided.

* Indicates Response Required