Preceptorship Grant Application

STATE OF ARIZONA - GRANT PROGRAM FOR PRECEPTORS OF HEALTHCARE GRADUATE STUDENTS
Eligibility:

To apply for the preceptorship grant with the Arizona Dental Association you must meet the following criteria:
- Be a dentist or specialist who is licensed pursuant to Arizona Revised Statutes, Title 32, and in good standing.
- Provide an uncompensated mentoring experience.
- Serve as a volunteer preceptor for an Arizona graduate dental student with training lasting a minimum of four weeks (beginning on or after January 1, 2023)
- Provide an educational opportunity for the graduate student to enable the student to obtain an eligible professional degree.
Award Amount:

Preceptors are eligible to receive a grant of $1,000 (one thousand dollars) per state fiscal year (July 1 – June 30) regardless of the number of preceptorships the applicant provides in that year.
Application Instructions:
- Submit one application per state fiscal year (July 1 – June 30).
- Only list preceptorships that have concluded, do not list preceptorships that are ongoing.
  - Listing ongoing preceptorships will result in a delay in processing your application.
- Submit your W-9, Professional License and Certificate of Insurance (if applicable) along with your application.
Please email Preceptor@azda.org with any questions.
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
NPI*
AZ License Number*
Credentials*
Focus/Certification*
Address of Record for Preceptor's License*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Student 1 Information
Student Precepted:*

First NameLast Name
Setting for Preceptorship (OTC, private practice, etc.):*
Name of educational institution/program or residency:*
Educational institution/program
Location of student/graduate:*
City
Start Date:*

MonthDayYear
End Date:*

MonthDayYear
Provide a brief description of learning that took place during this preceptorship:*
Verification of Student Program Enrollment*

Browse Files

Cancelof

Student 2 Information
Student Precepted:

First NameLast Name
Setting for Preceptorship (OTC, private practice, etc.):
Name of educational institution/program or residency:
Educational institution/program
Location of student/graduate:
City
Start Date:

MonthDayYear
End Date:

MonthDayYear
Provide a brief description of learning that took place during this preceptorship:
Verification of Student Program Enrollment

Browse Files

Cancelof

Student 3 Information
Student Precepted:

First NameLast Name
Setting for Preceptorship (OTC, private practice, etc.):
Name of educational institution/program or residency:
Educational institution/program
Location of student/graduate:
City
Start Date:

MonthDayYear
End Date:

MonthDayYear
Provide a brief description of learning that took place during this preceptorship:
Verification of Student Program Enrollment

Browse Files

Cancelof

Required Documentation
W-9*

Browse Files

Cancelof
Professional License*

Browse Files

Cancelof
Certificate of Insurance*

Browse Files

Cancelof

Attestation
I have read and completed this application an attest that its contents are true and correct*

YesNo
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear

Should be Empty:

STATE OF ARIZONA - GRANT PROGRAM FOR PRECEPTORS OF HEALTHCARE GRADUATE STUDENTS

Healthcare organization where Preceptorship took place:

Student 1 Information

Student 2 Information

Student 3 Information

Required Documentation

Attestation