Preceptor Application

If you experience any issues submitting this form, please contact webteam@pcom.edu.

If you see this don't fill out this input box.

*Indicates required field

Your Information

*First Name

Middle Initial

*Last Name

*Degree

*Phone

Fax

*Email Address

*Facility/Practice Name

Department/Suite

*Street Address

*City

*State

*Zip Code

*Primary Contact (to schedule students)

*Contact Phone Number

Contact Fax Number

Contact Email Address

Please provide the names of additional Practitioners who will share teaching responsibilities:

Practice Details

Practice/Facility Type:

Other Information

Please email a current copy of your curriculum vitae to Clinical Director Paul Krajewski, PA-C at paulkr@pcom.edu.

Your medical license number (optional):

Additional comments or information:

PENNSYLVANIA

PCOM
4170 City Avenue
Philadelphia, PA 19131
Phone: 215-871-6100
Email: admissions@pcom.edu

PCOM Georgia
625 Old Peachtree Road NW
Suwanee, GA 30024
Phone: 678-225-7500
Email: GAadmissions@pcom.edu

PCOM South Georgia
2050 Tallokas Road
Moultrie, GA 31768
Opening Fall 2019
Learn More
Phone: 229-668-3110
Email: sogaadmissions@pcom.edu