Preceptor Information First Name * Last Name * Practice Street Address * City * Zip * Office Phone * Cell Phone * E-mail Address * Office Contact Person * Site Visit AvailabilityPlease indicate which days/hours would be most convenient for the Director of Clinical Education to visit your practice site: Degree * MD DO PA FNP Practice Specialty? * Family Medicine Internal Medicine Pediatrics Women’s Health Behavioral Medicine Surgery Emergency Medicine Critical Care Other Board Certified? * Yes No State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming Weekday mornings (8am-11am) M T W Th F Lunch hour (Noon - 2pm) M T W Th F Weekday afternoons (2pm - 5pm) M T W Th F Please type the letters and numbers shown in the image. Click the image to see another captcha.
