Preceptor Information

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)*

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.

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 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*

Gender*

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*

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.

*

RSA Fellowship Network - Preceptor Enrollment

PRECEPTOR ENROLLMENT

COMMITMENT LETTER