Request for Clinical Affiliation Agreement

Program/Course:BSN 423MSN FNPMSN NEMSN NAMSN CNLMSN CNS

Name of Student:

Student ID #:

Student Phone #:

Student Email:

Course #:

Term of enrollment for identified course:FallWinterSpringSummer

Name of Agency:

Address of Agency: Street address, city, state, and zip

Administrator/Chief Nurse Executive:
Types of appropriate individuals include owner, directors of nursing, chief nurse executives, or directors of education

Title:

Email address:

Agency Phone #:

Agency Fax #:

Agency Website:

If the agency participates in a placement consortium, select which one:
Orange County/Long Beach ConsortiumCentral Computer Placement System (CCPS)San Diego ConsortiumInland EmpireSan Francisco CCPSOther

Other Placement Consortium