REQUEST FOR CLINICAL AFFILIATION AGREEMENT

Please provide all necessary information to expedite the process. Allow a minimum of 4 weeks for

processing. Once you finish, click submit.

 

MSN deadline for spring courses is November 1st
MSN deadline for summer courses is April 1st
MSN deadline for fall course is June 1st
 

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Program/Course:  BSN 411 BSN 421   BSN 451

MSN-FNPMSN-NE MSN-NA MSN-CNL MSN-CNS

Name of Student: 

Student ID#:       

Student Phone#: 

Student Email:     

Course #:   (Example: BSN 421)   Term of enrollment for identified course:

Name of Agency:    

Address of Agency: Please type the full address here (street address, city, state, and zip)

Administrator/Chief Nurse Executive:

(Types of appropriate individuals include owner, directors of nursing, chief nurse executives and 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 Consortium

Central Computer Placement System (CCPS)

 San Diego Consortium

Inland Empire (San Bernardino/Riverside counties)

San Francisco CCPS

 Other  Specify