COP Lecturer and Preceptor Interest Form

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* = required field

I am interested in *

Precepting

Lecturing

Assisting in skills-related activities

Admissions Interviews

Other

Other Interest if applicable

Legal Name *

First

Last

Email Address *

Phone Number *

CV or Resume *

Allowed File Types: doc, docx, pdf

Affiliated Site (Work Location)

Affiliated Site Name *

Site Address *

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Affiliated Site Phone Number *

If applicable, please list your specialty area(s)

Appointments at Peer Institutions