Burrell College of Osteopathic Medicine Forms

Faculty/Contractor Information Sheet

Date Completed:

MM slash DD slash YYYY

Basic Information

Name:(Required)

First Last

Birthdate:(Required)

Month

Day

Year

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Phone:(Required)

Alternate Phone:

Primary Email Address:(Required)

Enter Email Confirm Email

Alternate Email Address:

Enter Email Confirm Email

Demographic Information

Gender:(Required)

Race:(Required)

Professional Information

Board Certified:(Required)

If yes, Certified By:

Specialty:

Licensed:(Required)

If yes, License Number:

License State:

Academic Information

Highest Degree:(Required)

Institution:(Required)

Do you hold any academic appointments?(Required)

1st Academic Appointment Title, Department, Institution (If yes…):

2nd Academic Appointment Title, Department, Institution (If applicable):

3rd Academic Appointment Title, Department, Institution (If applicable):

Resume/Curriculum vitae:

Upload Current CV:

Accepted file types: pdf, doc, docx, png, jpg, Max. file size: 8 MB.

In Case of Emergency – Emergency Contact:

Name:(Required)

First Last

Phone Number:(Required)

Are you a physician?(Required)

Yes

Additional Required Questions.

License Information(Required)

Has your license to practice medicine in any jurisdiction ever been refused, limited, suspended, or revoked?

Yes

Hospital Privileges Information(Required)

Have your privileges on any hospital staff ever been refused, limited, suspended, revoked, diminish or non-renewed?

Yes

DEA registration Information(Required)

Has your DEA registration or State controlled substance certificate ever been limited or suspended or revoked?

Yes

Conviction Information(Required)

Have you ever been convicted of a misdemeanor or a felony (other than a minor traffic violation)?

Yes

Explanation

If you responded YES to any of the Additional Required Questions, please explain:

I warrant that all the information that I have provided and the responses that I have given are correct and complete to the best of my knowledge and belief.

I understand that any misrepresentation or omission will be sufficient cause for cancellation of a contract and/or removal from the faculty roster.

By submitting I hereby certify that this information provided to Burrell College is true and correct

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