Contract Request Form

Request for Contract

Please complete the items below. Feel welcome to reach out to CON-contracts@arizona.edu with any questions.
Student Name*

First NameLast Name
Program*
Please select the program you are currently enrolled in.
Agreement Type:*

Clinical PlacementTeaching PracticumNon-clinical PlacementOther
If other, please explain:*
Request Submitted By*

StudentOther
Requestor's Name*

First NameLast Name
Requestor's Email*
example@example.com
When is placement scheduled to begin?*

MonthDayYear
Date
Site's Legal Name*
Site's Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Site Contact Name*

First NameLast Name
Site Contact Credentials
DNP, MD, PMHNP, FNP, etc.
Site Contact Phone Number*

Area CodePhone Number
Site Contact Email*
Will the preceptor/site accept the standard UA contract or do they prefer to use their standard contract?

Yes, will accept UA contractPrefers to use their standard contract
Special Notes
If you have any additional information you would like to add, please do so here.
Who will be supervising the student(s)?*

UA Faculty SupervisorSite Preceptor
Preceptor Name*

First NameLast Name
Preceptor's Credentials*
DNP, MD, PMHNP, FNP, etc.
Preceptor Phone Number*

Area CodePhone Number
Preceptor Email*
Who provides the preceptor's Professional Liability Insurance?*
Who is authorized to sign the contract?*

PreceptorOther
Signer's Name*

First NameLast Name
Signer's Credentials
DNP, MD, PMHNP, FNP, etc.
Signer's Title*
Office Manager, Owner, CFO, etc.
Signer's Email*
example@example.com
Where does the preceptor treat patients?*
Should be Empty:

Request for Contract