Preceptor and Facility Agreement

Student IDs begin with 5000xxxxxx or 6000xxxxxx
Some older Student IDs have the format xxx-xxxxxx.
 
(Use Patriot's Email)
Contact: Lindsey Heaton, 903.565.5569

Preceptor Information

Is this Preceptor listed in Typhon? *
Gender: *
calendar calendar
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.