(typewritten only)

Applicant Information:

Last Name:	_____________________________________________
First Name:	_____________________________________________
Date of Birth:	_____________________________________________
Permanent Home Address:	_____________________________________________
	_____________________________________________
	_____________________________________________
	_____________________________________________
Home Telephone #:	_____________________________________________
Name of University/Hospital:	_____________________________________________
Complete Address of Hospital:	(If you are in private practice, please explain your position and indicate name and address of primary hospital.)
	_____________________________________________
	_____________________________________________
	_____________________________________________
	_____________________________________________
Hospital Office Telephone #:	_____________________________________________
Hospital/Office Fax #:	_____________________________________________
Present Position:	_____________________________________________
Academic Appointment:
Institution:	_____________________________________________
Title:	_____________________________________________
Circle One:	Private Practice - Clinical Faculty - Full time Faculty
Year of Certification/Fellowship:	_____________________________________________
Expected Dates of Preceptorship:	_____________________________________________

Preceptor Information:

Last Name:	_____________________________________________
First Name:	_____________________________________________
Complete Title:	_____________________________________________
Name of University/Hospital:	_____________________________________________
Complete Address of Hospital:	_____________________________________________
	_____________________________________________
	_____________________________________________
	_____________________________________________
Hospital/Office Phone #:	_____________________________________________
Hospital/Office Fax #:	_____________________________________________

IMPORTANT:
To the Applicant:

Please attach your current CV, plus a letter or memorandum outlining your reasons for wanting to do this preceptorship: your needs, objectives, and what you expect to gain from it.

This memo or letter must be agreed to and signed by the host preceptor and forwarded with this application to the AO North America office.

Once the above information is compiled, and required documents attached, you should send the completed application to: