Preceptorship Application

NP, PA or Medical Students that are requesting a preceptorship or any student looking for a NP, PA or Physician job shadow should complete the application below.

Bio Information



Current Address


Permanent Address

Check this box if your permanent address is the same as what you already entered above for your current address.

Preceptorship Details



Enter a date range in which you are available to complete your rotation.

Enter a date in which you are available for your job shadow.


Provider Preferences

Please provide the names and specialties of the three providers that you would prefer to shadow or be with for your clinical rotation. Use our online provider directory if you need help identifying 3 preferred physicians.


Additional Comments

If you have any additional comments or clarifications about your request or the date(s) in which you are available, please provide those details here.