AO North America


APPLICATION FOR BASIC FRACTURE MANAGEMENT PRECEPTORSHIP
(Senior Resident Elective Rotation)


P.O. Box 308 Devon, PA 1933-0308
Phone: (610) 251-9007
Fax: (610) 251-9059

Information pertaining to applicant:

NAME, DATE OF BIRTH, HOME ADDRESS, HOME TELEPHONE:


NAME AND ADDRESS OF UNIVERSITY/HOSPITAL TRAINING PROGRAM:


NAME OF HEAD OF DEPARTMENT:


YOUR HOSPITAL/OFFICE TELEPHONE AND FAX:


DIRECTOR OF ORTHOPAEDIC TRAUMA:


PLEASE SELECT YOUR PRESENT LEVEL OF TRAINING:
PGY 4
PGY 5
OTHER


HAS YOUR RESIDENCY DIRECTOR APPROVED THIS PROPOSAL?


Information Pertaining to Preceptor:

NAME AND COMPLETE TITLE:


NAME, ADDRESS, TELEPHONE, AND FAX OF UNIVERSITY/HOSPITAL:


HOW LONG ON AO FACULTY:


AO FELLOWSHIP? IF SO, WHERE/WHEN:


DOES YOUR ORTHOPAEDIC PROGRAM DIRECTOR APPROVE OF THIS PROPOSAL?


TO THE APPLICANT: After submitting this form online, please send an outline of the reasons for requesting this Preceptorship and your expectations of this experience (see guidelines). Your outline must then be reviewed and signed by the Preceptor and returned to the AO North America office for approval. In addition to this, a letter of support from the Director of the program or the Department Chairman is also required.

AO North America
P.O. Box 308
Devon, PA 19333-0308
Fax: (610) 251-9059


Press this button to submit your request:

Thank you for your interest in AO/ASIF Continuing Education!