• Home
  • Experience
  • Benefits
  • Credentialing
  • Meet the Fellows
  • Fellowship Sites 
  • Committee
  • Apply
RSA Fellowship Network
  • Home
  • Experience
  • Benefits
  • Credentialing
  • Meet the Fellows
  • Fellowship Sites 
  • Committee
  • Apply
  • PRECEPTOR ENROLLMENT
    ~ SEEKING BRILLIANCE, PASSION, AND DEDICATION ~
    RSA FELLOWSHIP NETWORK

*

RSA Fellowship Network - Preceptor Enrollment

  • PRECEPTOR ENROLLMENT

  • COMMITMENT LETTER

  • (Click Here) to review the Preceptor Commitment Letter for the participation in the RSA Fellowship Network 2022/2023.
  • By completing the form below, I submit my enrollment as a Fellowship Preceptor and Founder in the RSA Fellowship Network. I have reviewed the Preceptor’s Invitation Letter Dated January 26, 2022, (Click Here to Download) and acknowledge the scope of the program. I understand this program provides each Fellow with a unique “networked” format for the fellowship and entitles them to participate in extensive training in a virtual environment, as well as access to electives at other RSA clinical sites and other programs. I further understand that my Enrollment Fee is non-refundable.
  • $0.00
    I understand that this enrollment fee is displayed in USD and is non-refundable and non-transferable. I further understand that I am responsible for any additional fees/expenses which may be required to fulfill this application process.
  • PRECEPTOR INFORMATION

  • Please provide the name of the board which awarded your certification(s). i.e. ABO for American Board of Ophthalmology or MBBS for Bachelor of Medicine, Bachelor of Surgery.
  • Please provide any Academic Appointments, Titles, etc...if any
  • PRACTICE / SITE INFORMATION

  • INCOMING 2022 FELLOW INFORMATION

  • Please provide the full name of the Residency Program your Fellow attended.
  • ADMINISTRATIVE CONTACT INFORMATION

  • ENROLLMENT & FEE SUBMISSION OPTIONS

  • Upon clicking the "Submit & Pay Preceptor Feeby Credit Card" you will be redirected to the PayPal website to pay your "Preceptor Fee".
  • BENEFICIARY / RECIPIENT INFORMATION:
    The information below will allow you to make the wire transfer of the Preceptor Fee:

    Beneficiary Name: Refractive Surgery Alliance Corporation
    Beneficiary Address: 28071 North 90th Way Scottsdale, AZ 85262 USA
    Beneficiary Bank: Wells Fargo Bank NA 420 Montgomery Street San Francisco CA 94104 USA
    Beneficiary Account #: 1545479287
    Amount to Transfer: $ 15,000.00 USD
    Funds to be sent in: USD
    ABA/RTN: 121000248
    SWIFT Code: WFBIUS6WFFX
    Memo Line: RSA Preceptor Fee Level 1
  • Upon clicking the "Submit & Pay Preceptor Fee by Wire Transfer" you agree to make a wire transfer of the Preceptor Fee within five (5) business days of submitting this Preceptor Enrollment.
  • BENEFICIARY / RECIPIENT INFORMATION: Please make your Preceptor Fee check payable to and mail to the following:

    Make Chek Payable to: Refractive Surgery Alliance Corporation
    Mailing Address: 28071 North 90th Way Scottsdale, AZ 85262 USA
    Amount: $ 15,000.00 USD
    Funds to be sent in: USD
    Memo Line: RSA Preceptor Fee Level 1
  • Upon clicking the "Submit & Pay Preceptor Fee by Check" you agree to make payment of the Preceptor Fee by check within five (5) business days of submitting this Preceptor Enrollment.
  • This field is for validation purposes and should be left unchanged.

*

Contact Us

How may we be of assistance?

Send Message
  • RSA Fellowship Network is a Product of the Refractive Surgery Alliance Corporation
  • 28071 North 90th Way ~ Scottsdale ~ Arizona ~ 85262 ~ USA
  • +1.480.664.1800
  • +1.480.664.1881
  • Admin@RSAFellow.com
  • www.RSAFellow.com

Application Timeline

~ Stage 1: Apply: Rolling Application

~ Stage 2: Interviews: Rolling Interviews

~ Stage 3: Fellow Match: Rolling Fellow Selections

The RSA Fellowship Network… APPLY HERE

© 2023 · Your Website. Theme by HB-Themes.

  • Home
  • Experience
  • Benefits
  • Credentialing
  • Meet the Fellows
  • Fellowship Sites 
  • Committee
  • Apply