For further information, please contact the Office of Experiential Education (

Section 1
Personal Information
Primary Site Information
Alternate Site Information
Licensure Information
Professional Association Memberships

Check all professional associations that you are a member of:

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

Does your Site have Pharmacy Residents?

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

Section 2
Curriculum Vitæ / Résumé

Please submit CV or resume:

Please submit proof of active license:

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

Section 3
Other Interests

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?

Are you interested in precepting APPE Students?

Do you have experience precepting pharmacy students?

Would you like to precept an APPE elective?

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

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

Section 4
Confidential Information

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

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: