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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.
JULY 2022 thru JUNE 2023 (LEVEL 1 FELLOWSHIP)
*
Enrollment as a Preceptor for Level 1 RSA Fellowship Network.
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.
PRECEPTOR FEE (USD)
$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
FULL NAME & CREDENTIALS:
*
First
Middle
Last
Credentials (MD, DO, MBBS, etc...)
Certifying Board
*
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.
Academic Appointments (if Any)
Please provide any Academic Appointments, Titles, etc...if any
PERSONAL EMAIL:
*
Enter Email
Confirm Email
PERSONAL CELL PHONE NUMBER:
*
PRACTICE / SITE INFORMATION
Practice Name
*
PRACTICE ADDRESS:
*
Street Address
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
PRACTICE PHONE NUMBER:
*
PRACTICE WEBSITE:
*
HAVE YOU IDENTIFIED/CONTRACTED FOR AN INCOMING 2022 FELLOW YET?
*
YES!
No, Not Yet.
INCOMING 2022 FELLOW INFORMATION
FELLOW FULL NAME & CREDENTIALS:
*
First
Middle
Last
Credentials (MD, DO, MBBS, etc...)
Date of Birth
*
Month
Day
Year
Gender
*
<Select>
Female
Male
Fellows Email Address
*
Enter Email
Confirm Email
Fellows Cell Phone
*
Fellows Residency Program
*
Please provide the full name of the Residency Program your Fellow attended.
ADMINISTRATIVE CONTACT INFORMATION
NAME OF ADMINSITRATIVE CONTACT @ PRACTICE
*
Administrative Contact Email Address
*
Enter Email
Confirm Email
ENROLLMENT & FEE SUBMISSION OPTIONS
METHOD OF PAYMENT FOR MY PRECEPTOR FEE
*
<Form of Payment>
Credit Card
Wire Transfer
Check
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.
Email
This field is for validation purposes and should be left unchanged.
*
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