Please complete the request form and submit for consideration.If you are a student this application will be deleted, it is only to be completed by the school/entity wanting an affiliation. In order to consider your request for an affiliation agreement in the school contact section we need to know the school contact's full name, title, e-mail, phone number, address, fax number. If any of these are left out it will hold up processing of this request.

New Affiliation Agreement Request can take between 90 and 120 days to be fully executed. This application is not a guarantee of acceptance or approval. Applications for new agreements can be declined for any reason.

Name and address of Requestor

First name:

Last name:

Title:

Street 1:

Street 2:

Street 3:

City:

State:

* Zip: *

Work phone:

Cell phone:

Fax phone:

Email address:

Web site:

What type of school?

Is this a state run Virginia school, private Virginia school, or out of state school?

College:

Is this a state run Virginia school, private Virginia school, or out of state school?

School Program

Date Needed

School contact/Address/E-mail

Any additional information?

What type of students will you be sending?

Please list the type of students you will send to Bon Secours Virginia.

Is the school accredited?

Please give information on accreditation