Clinical Preceptor Recognition Program Application

Welcome and thank you for your interest in the Clinical Preceptor Recognition Program!

Application Requirements:

To be eligible for the recognition program, you MUST meet all three requirements.

Be a current AAPA fellow member
Have served as a preceptor for at least 8 weeks on average for the last two years
Be endorsed by a PA program(s) that you have supported as a preceptor.

Instructions:

Please complete the application below with as much detail as possible
Please pass along this endorsement form to the PA program(s) you have precepted for (they can also complete the form in PDF and email/fax to return).

Save & Return

Use an account to return to saved work.

First Name *

Last Name *

AAPA ID: *If you do not know your AAPA ID, contact AAPA Customer Care at 703-836-2272, Option 1, M-F, 9-5 ET *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Precepting History:

Please list the number of students you precepted, the year, total number of weeks during that year and the PA program name. If you precepted for more than one PA Program during the same calendar year, please list as separate line items.

	Number of Students	Year	Number of Weeks	PA Program
1.	Number of Students	Year	Number of Weeks	PA Program
2.	Number of Students	Year	Number of Weeks	PA Program
3.	Number of Students	Year	Number of Weeks	PA Program
4.	Number of Students	Year	Number of Weeks	PA Program
5.	Number of Students	Year	Number of Weeks	PA Program

PA Program References:

Please fill in the appropriate information in the fields below.

	PA Program	Contact Name	Title	Phone	Email
1.	PA Program	Contact Name	Title	Phone	Email
2.	PA Program	Contact Name	Title	Phone	Email
3.	PA Program	Contact Name	Title	Phone	Email
4.	PA Program	Contact Name	Title	Phone	Email

Mailing Information:

If you are unable to use the online application, please contact AAPA at cp@aapa.org for assistance. You may also print the application, and fax or mail it to AAPA

American Academy of Physician Assistants

2318 Mill Rd. Suite 1300

Alexandria, VA 22314

P 703-836-2272, Option 1

F 571-519-4313

*

By checking, here I authorize AAPA to the verification of the information provided on this form.