Preceptor Sign-Up Form
  1. Contact Information


  2. (*)
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  8. (*)
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  9. Phone Number must be in 555-555-5555 format
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  11. Medical College Preference



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  12. Type of Practice(*)





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  13. Time Willing to Precept



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  14. Are you able to provide housing?(*)
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  15. Additional Preceptors


  16. Please list the name and email of colleagues who may be interested in being preceptors, either this year or in the future
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  17. Please list Clinic, Hospital Affiliate, or other source that may be able to provide funding for an Externship
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Wisconsin Academy of Family Physicians - Foundation  |  210 Green Bay Road  |  Thiensville, WI 53092
Phone: (262) 512-0606  |  Fax: (262) 242-1862
 
WAFP-F is a 501(c)3 non-profit organization. Your donation is tax deductible to the extent allowed by law.
No goods or services are provided in exchange for your financial donation.

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