Preceptor Authorization Form

 

Name _____________________

SS #   _____________________

Mailing Address  _________________________

                         __________________________

                         __________________________

Work Phone # (505) _________ Home Phone # (505)__________
 
Fax # (505) ________________ Email: _____________________

If applicable , please fill out the following:

 

 

Please return this form to:

 

AHEC/Preceptorship Office
CRTC, Room B-76
Albuquerque, NM 87131-5130
505-272-3510, 800-481-3375
505-272-8498 (fax)

 

 

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