School of Pharmacy and Pharmaceutical Sciences

Check all professional associations that you are a member of:

PSSNY AMCP Topco NYSCHP NCPA NACDS APha ACCP ASHP ASCP Other

Are you the Contact Preceptor or Site Coordinator for this site?

Contact Preceptor Site Coordinator Both Neither N/A

Does your Site have Pharmacy Residents?

Yes No

If so, how many and what type (e.g. PGY-1, PGY-2 Geriatrics)?

Do you want a faculty appointment to Binghamton University School of Pharmacy and Pharmaceutical Sciences?

Yes No N/A

Please submit CV or resume:

Please submit proof of active license:

If not in your CV, please list Post-Graduate Training and Certifications below:

The School will be looking for Preceptors who would like to play a supporting role for our didactic/skills curriculum and in research education and activity. Below you will find a series of questions:

Are you interested in precepting IPPE Students?

Yes No

Are you interested in precepting APPE Students?

Yes No

Do you have experience precepting pharmacy students?

Yes No

Would you like to precept an APPE elective?

Yes No

Would you like to be involved in teaching an advanced elective in the second or third year of the curriculum?

Yes No

Are you interested in precepting a research elective? IPPE? APPE?

Yes No

Has your license ever been suspended or revoked in any state or have you ever been disciplined?

Yes No

By checking "I Agree" box below, I here expresses my willingness to become a preceptor/member of the adjunct faculty of Binghamton University School of Pharmacy and Pharmaceutical Sciences and that the information I have provided herein is accurate.

I place my signature below to verify this statement: