W-9 form.pdf107.83 KB
Elaine Stapleton, Credentialing Coordinator
LMU-DCOM Osteopathic Medicine Program
Fax: 4
All information contained in this form will remain confidential.
Please submit the following with this application (Applications cannot be processed until all documents below have been submitted)
  • Current typed CV
  • Copy of current license
  • Board Certification, if applicable
  • Downloadable W-9 form attached at end of the application (for compensation to which you may be entitled)
  • The Office of CME and Preceptor Development is offering a free faculty development program to our clinical educators (physicians precepting students). The program may be completed in a self-paced online format or by attending one of the live workshops offered at various LMU-DCOM clinical training sites. Participants may choose to receive CME credits for participating. Completion of this program is strongly encouraged. If completed at the time of application, please attached a copy of the completion certificate. The links for the online format are listed below:

          - Click here for CME course
          - Click here for non-CME course

TO:  Elaine Stapleton, Credentialing Coordinator
via Email: 
or  Fax: 
or  Mail: LMU-DCOM, 6965 Cumberland Gap Parkway, Harrogate, TN  37752

For CME reporting purposes
I agree to accept a minimum of 2 students during the 3-year appointment period, if requested.
I agree to accept a minimum of 2 students during the 3-year appointment period, if requested.
I agree to provide at least 2 on-campus presentations during the 3-year appointment period, if requested.
I certify by typing or signing my name above that all statements in this application are true and complete. I authorize administrative official of the Lincoln Memorial University – DeBusk College of Osteopathic Medicine to make inquiries necessary to verify my professional qualifications, my adherence to the professionalism standards of my profession, my reputation and ability to teach and appropriately work with medical and/or physician assistant students.
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