Preceptor Renewal

RSA PRECEPTOR RENEWAL

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 FELLOW & LEVEL 2 ASSOCIATE)*

By completing the form below, I submit my renewal as a Fellowship Preceptor in the RSA Fellowship Network. I have reviewed the Preceptor’s Invitation to Participate Letter Dated January 26, 2022, (Click Here to Download) and agree to the scope of this program which provides each Fellow/Associate 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 Country

PRACTICE PHONE NUMBER:*

PRACTICE WEBSITE:*

HAVE YOU IDENTIFIED/CONTRACTED FOR AN INCOMING 2022 FELLOW YET?*

YES!
No, Not Yet.

INCOMING 2022 LEVEL 1 FELLOW INFORMATION

LEVEL 1 FELLOW: FULL NAME & CREDENTIALS:*

First Middle Last Credentials (MD, DO, MBBS, etc...)

LEVEL 1 FELLOW: Date of Birth*

LEVEL 1 FELLOW: Gender*

LEVEL 1 FELLOW: Residency Program*

LEVEL 1 FELLOW: Email Address*

Enter Email Confirm Email

LEVEL 1 FELLOW: Cell Phone*

CONTINUING 2022 LEVEL 2 ASSOCIATE INFORMATION

LEVEL 2 ASSOCIATE: FULL NAME & CREDENTIALS:*

First Middle Last Credentials (MD, DO, MBBS, etc...)

LEVEL 2 ASSOCIATE: Email Address*

Enter Email Confirm Email

LEVEL 2 ASSOCIATE: Cell Phone*

ADMINISTRATIVE CONTACT INFORMATION

NAME OF ADMINSITRATIVE CONTACT @ PRACTICE*

Administrator Email Address*

Enter Email Confirm Email

Administrator Cell Phone*

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: $ 20,000.00 USD
Funds to be sent in: USD
ABA/RTN: 121000248
SWIFT Code: WFBIUS6WFFX
Memo Line: RSA Preceptor Renewal Fee

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: $ 20,000.00 USD
Funds to be sent in: USD
Memo Line: RSA Preceptor Renewal Fee

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.

Comments

This field is for validation purposes and should be left unchanged.

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RSA Fellowship Network - Preceptor Renewal - Enrollment of Two Fellows (Year 1 Fellow & Year 2 Associate)

RSA PRECEPTOR RENEWAL

COMMITMENT LETTER

PRECEPTOR INFORMATION

PRACTICE / SITE INFORMATION

INCOMING 2022 LEVEL 1 FELLOW INFORMATION

CONTINUING 2022 LEVEL 2 ASSOCIATE INFORMATION

ADMINISTRATIVE CONTACT INFORMATION

ENROLLMENT & FEE SUBMISSION OPTIONS

*