The Proposed Larkin College of Osteopathic Medicine
Inaugural Preceptor Application
Help shape the future of medicine by mentoring the next generation of physicians.
Name
*
First Name
Last Name
Degree(s)/Credentials
Example: DO, MD, PhD, MPH
In what state are you currently licensed to practice?
Please Select
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
West Virginia
Wisconsin
Wyoming
Medical License Certification Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical License Expiration Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
License number:
*
What is your primary specialty?
*
What board certifying organization applies to your primary specialty?
*
AOA
ABMS
Other
Are you Board Certified or Board Eligible in your primary specialty?
*
Board Certified
Board Eligible
Neither
What is the expiration date of your board certification/OCC/MOC?
*
Enter "N/A" if you hold lifetime certification.
Do you have a secondary specialty?
*
Yes
No
What is your secondary specialty?
*
What board certifying organization applies to your secondary specialty?
*
AOA
ABMS
Other
What is the expiration date of your secondary specialty certification/OCC/MOC?
*
Enter "N/A" if you hold lifetime certification.
Do you prefer being a preceptor on campus or clinical site?
*
On Campus
Clinical Site
Both
Contact Number:
*
Format: (000) 000-0000.
Office Contact Number:
Format: (000) 000-0000.
E-mail
*
example@example.com
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Submit
Should be Empty: