Placement Request Form for: NP Students and Out-of-State Students

Please complete all sections.
You should submit request form as soon as your rotation dates are confirmed.
You will be notified by (email or phone) once your form is received to discuss your request.

If you have any questions, please feel free to call Julie Ghent at (803) 286-4121 or email her at jughent@comporium.net

 Rotation 1Rotation 2 (if applicable)Rotation 3 (if applicable)
Course Name and No.
Rotation Site/ Preceptor Nameor Preferred Rotation Location(i.e. facility, city, or county preference)
Rotation Dates (Begin and End)
Do you need AHEC Housing? If yes, please indicate the housing dates (Begin and End)