Request for Affiliation Agreement Form

Your Email Address * Required
Will affiliate accept CHP’s standard affiliation agreement? * Required
- Yes
- No
If yes, an affiliation agreement will be created from the information below. If no, please email an electronic copy of affiliate's agreement to CJ Carrell; Word files preferable.
Affiliate Information
Legal Name of Affiliate * Required
Name of Person Signing the Agreement * Required
Title of Person Signing the Agreement * Required
Name of Second Person Signing the Agreement

Additional person ONLY if needed.
Title of Second Person Signing the Agreement

Additional person ONLY if needed.
Name of Third Person Signing the Agreement

Additional person ONLY if needed.
Title of Third Person Signing the Agreement

Additional person ONLY if needed.
Affiliate Mailing Information
Contact Person * Required
Prefix First Last
Contact Person's Title * Required
Mailing Address * Required
Street Address City State ZIP Code
Phone * Required
Fax * Required
Email * Required
Student Information
Date student needs to start clinical rotations (Month, Date, Year) * Required

Please spell out the name of the month rather than using the number format (e.g., "September 15, 2014" instead of "09/15/2014")
CHP Program/Division/Department Information
Program/Division/Department * Required
Faculty/Chair requesting agreement * Required
First Last

Affiliate Information