UNIVERSITY OF SOUTH ALABAMA
COLLEGE OF NURSING
Request to Establish an Affiliation Agreement
To initiate the affiliation agreement process, complete and submit this form to the
Specialty Track Coordinator.
This request form is to be utilized for agencies that will not sign the USA Two-Page
Agreement. For more information, please refer to the College of Nursing guidelines for
processing affiliation agreements.
1.
Agency Name: _____________________________________________________
2.
Agency Contact Person: _____________________________________________
(Full name and title)
3.
Email Address: _____________________________________________________
4.
Agency Address: ___________________________________________________
___________________________________________________
Phone Number: ____________________________________________________
5.
Name of Student (if applicable): _______________________________________
6.
Semester/Year student(s) plan to start clinical/practicum: ___________________
7.
Course Number/Name: ______________________________________________
8.
Specialty Track: ____________________________________________________
9.
Track Coordinator/Course Coordinator: _________________________________
__________________________________________________________________
RL/bc
Revised 1/2014