Preceptor Interest Form

First Name*

Last Name*

Email*

Phone*

CA RPh license number

Current practice facility (name of hospital, pharmacy, clinic, business, etc.)

City of current practice site

Have you precepted Pharm.D. students from any school in the past 5 years?

Yes

Pharmacy degree institution (university, school, or college)

Year pharmacy degree earned

Are you a UCI alum?

Yes

Are you interested in joining our extended alumni network “Anteaters in Pharmacy”?

Yes

I’m already part of Anteaters in Pharmacy. Zot Zot Zot!

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Irvine, CA 92697
949.824.1991

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Irvine, CA 92697-3958

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