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Preceptors Name:______________________________________________________________
Office Address:_______________________________________City______________________
State:_______________________Zip C o d e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
O f f i c e P h o n e N u m b e r : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ E - m a i l : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
P r e f e r r e d M e t h o d o f C o n t a c t : ( P h o n e ( e - m a i l
C r e d e n t i a l s : ( M D ( D O ( N P ( P A R N O t h e r _ _ _ _ _ P r o f e s s i o n a l L i c e n s e # : _ _ _ _ _ _ _ _ _ _ _
H i g h e s t d e g r e e h e ld: ( Masters ( DNP ( PhD (MD ( DO
State Issuing License:_________________Expiration Date:_____________________________
National Certification(s) held: _____________________________ NPs: ( ANCC ( AANP
MD or DO Specialty Certification:___________
All Preceptors: Years of Experience in Specialty:_____
College or University Degrees and Dates Awarded:___________________________________
___________________________________________________________________________
This Section to be Completed by S t u d e n t :
I A g r e e t o P r e c e p t ( S t u d e n t N a m e ) : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
C o u r s e N u m b e r a n d N a m e : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
S e m e s t e r : ( F a l l ( S p r i n g S u m m e r Y e a r : _ _ _ _ _ _ _ _ H o u r s t o b e C o m p l e t e d : _ _ _ _ _
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Program Director Lynne Palma DNP, FNP-BC, CDE
Cell 954 815-0644 E-mail HYPERLINK "mailto:Lpalma@fau.edu" Lpalma@fau.edu
CHRISTINE E. LYNNE COLLEGE OF NURSISNG
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