College of Pharmacy

COP Lecturer and Preceptor Interest Form

* = required field

I am interested in *

Precepting

Lecturing

Assisting in skills-related activities

Admissions Interviews

Other

Other Interest if applicable

Legal Name *

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Last

Email Address *

Phone Number *

CV or Resume *

Affiliated Site Name *

Site Address *

Street Address

Street Address Line 2

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State / Province / Region

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Affiliated Site Phone Number *

If applicable, please list your specialty area(s)

Appointments at Peer Institutions