Preceptor Selection Site

Please provide the following contact information:

Name

Phone

E-mail

My rotation period is:

July-August
September-October
November-December
January-February
March-April
May-June

My first choice for a preceptor site is:

My second choice for a preceptor site is:

My third choice for a preceptor site is:

Do you need accommodations?

No
Yes

Will your spouse be accompanying you on the rotation?

No
Yes

Please describe any extenuating circumstances you may have: