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Preceptor Information Form

Preceptor Information Form


Your Name(Required)
Name on licensure/alternative names
Placement decisions may be influenced by the acuity of patients
Prescription Authority(Required)
This upload will only accept “.doc” and “.pdf” file extensions. If you have your social security number on any of these documents, please redact it before uploading. As part of credentialing, we require a copy of your CV/Resume, license, and certification documents. The documents will be held securely in our system. * Required

Document Upload

Word documents and PDF can be uploaded. Please include all three pieces of documentation.
Drop files here or
Accepted file types: pdf, doc, docx, Max. file size: 5 MB.
    Maximum file size – 5 mega bytes.

    Clinical Site

    Please let us know about the location where you will be hosting students and where you are employed.
    Clinical site's physical address(Required)

    Contact Person

    Information on contact person for clinical site.
    Do you have an administrative assistant or someone at the site who coordinates providers?