Preceptor Application

Physician Assistant Studies

Kristy Bower
- Clinical Coordinator, College of Health Professions
- 570-484-2217
- 570-484-2540 (fax)
- kbower@commonwealthu.edu
Carrie B. Friese, MHS, PA-C
- Assistant Professor, Lead Clinical Coordinator, Commonwealth University - Lock Haven
- 570-484-2705
- cbf256@commonwealthu.edu

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

First Name

Middle Initial

Last Name

Degree

Phone

Formatted as 123-123-1234

Fax

Formatted as 123-123-1234

Curriculum Vitae

Upload a copy of your your curriculum vitae.

One file only.
25 MB limit.
Allowed types: pdf, doc, docx, odt, rtf, txt.

The primary contact is the person who will handle scheduling of students.

Primary Contact

Primary Contact Email

Primary Contact Phone

Formatted as 123-123-1234

Primary Contact Fax

Formatted as 123-123-1234

Practice/Facility Name

Department/Suite

Street Address

City

State

Zip

Practice Areas

Family Medicine

Internal Medicine

Pediatrics

OB/GYN

General Surgery

Emergency Medicine

Behavioral Medicine

Other

Practice/Facility Type

Additional Practitioners sharing teaching responsibilities

Name	Operations
Name

Medical License Number

Additional Comments or Information