Affiliation Agreement Request

* Required Field

Request Date Purpose for the Agreement Is the student a THR employee or Volunteer? * First Name of THR Preceptor * Last Name of THR Preceptor * Clinical Rotation Location * Student First Name * Student Last Name * Start Date *

College/University Information

(person responsible for schools contracts)

College/University Name * Program Name * Contact First Name * Contact Last Name * Contact Title * Address * City * State * Zip Code * Phone Number * Email Address * Colleges Authorized Signatory * Title *

Hospitalist Group

(information is required for 3-party agreement)

Name of Hospitalist Group First Name of Hosting Physician Last Name of Hosting Physician Address City State Zip Code Phone Number Email Address 3rd Party Signatory Contact Title

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College/University Information

Hospitalist Group

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Hospitalist Group

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