Preceptor Name: ___ (First) (Middle) (Last)

(Position/Title): ___

Academic Preparation

Credentials (circle one): DO MD NP Other_____

License Number_____State_____Expiration Date

(If appropriate)

Certification Agency_____ Expiration Date

(If appropriate)

If the Preceptor is a Nurse Practitioner or Nurse Midwife, WRITE-IN the name of the

Collaborating Physician ___

and his/her Certification_____Expiration Date_____

Certifying Agency

Years of Experience ___

Preceptor's Employing Agency

Name: ___

Agency Address:___

<div style="text-align: center;"><img src="imgs/img_in_image_box_0_0_1785_28.jpg" alt="Image" width="100%" /></div>

City State Zip Code County

Telephone with area code _____ Fax Number _____

Cell_____

Email Address

<div style="text-align: center;"><img src="imgs/img_in_image_box_1_1_2006_39.jpg" alt="Image" width="98%" /></div>

I agree to serve as preceptor for (Student)

Dates for implementing Scholarly Project

PRECEPTOR'S SIGNATURE DATE