Preceptor Information Form
Please complete the information below about yourself. Note: we MUST have at least one email address for you. The primary email address that you list will be shared with students and will be the main method of communication between you and us. If you have a secondary email, which is optional, you may include that as well but it will not be available to students.
Today's Date *
MM
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DD
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YYYY
Prefix *
Last Name *
Your answer
First Name *
Your answer
Preferred Name (nickname)
Your answer
Primary Email (shared with students) *
Your answer
Gender *
Job Position *
Your answer
Work Site *
Your answer
Work Address *
Your answer
Work Phone *
Your answer
Cell Phone (optional)
Your answer
Secondary Email (optional)
Your answer
Highest Professional Degree *
Your answer
Pharmacy School *
Your answer
Graduation Year *
Your answer
Pharmacy Preceptor Certificate? *
Residency/Fellowship Training
Licensed State(s) *
Your answer
Pharmacy Organizations Membership
Your answer
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