PLEASE REVIEW THE FOLLOWING INFORMATION PRIOR TO COMPLETING THIS FORM.

• This form must be submitted six months prior to the desired rotation start date.
• Before completing this form please be sure to fill out the attached Authorization Form and obtain a Program Letter of Agreement (PLA) with the receiving Ascension / Dell Med Program Director's or Sponsoring Physician's Signatures. You will be required to upload these documents at the bottom of this form.
• A visiting rotator must be a U.S. Citizen, Permanent Resident, or J-1 Visa Holder already within the United States in order to be eligible to rotate.
• Any outside rotators must contact the Texas Medical Board (TMB) for instructions on obtaining a Rotator Physician in Training Permit (PIT). Please contact TMB at pits@tmb.state.tx.us.
• It is the responsibility of the Visiting Resident to make sure the Ascension / Dell Med Program Coordinator and Program Director are aware of this rotation ahead of time and have authorized this rotation.