Placement Request Form for: NP Students and Out-of-State Students

Please complete all sections.
You should submit request form as soon as your rotation dates are confirmed.
You will be notified by (email or phone) once your form is received to discuss your request.

If you have any questions, please feel free to call Casey Cato at (803) 286-4121 or email at ccato@comporium.net

Name *

Date *

Day

Month

Year

Please Select *

Male

Female

Address *

Address (extra field)

City *

State *

Zip Code *

Phone # *

Email Address *

Emergency Contact *

Emergency Contact Phone # *

University/Department *

Degree Program *

Current year of training *

School Contact (Name, Phone #, Email)

	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
Course Name and No.	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
Rotation Site/ Preceptor Nameor Preferred Rotation Location(i.e. facility, city, or county preference)	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
Rotation Dates (Begin and End)	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)
Do you need AHEC Housing? If yes, please indicate the housing dates (Begin and End)	Rotation 1	Rotation 2 (if applicable)	Rotation 3 (if applicable)

Additional Rotation Information (ex: # of hours required, # of days per week, etc)