Clinical Instructor Application

The following are the requirements to become a clinical instructor (preceptor) for the Concordia University Wisconsin (CUW) School of Pharmacy (SOP) experiential learning program:
1. Licensed pharmacist for at least one year. PGY1 residents may serve as primary preceptors for IPPE students.

2. Pharmacist license is in good standing with the state Board of Pharmacy.

3. Participate and remain up to date in the CUW Clinical Instructor orientation and training program.

4. Understand and comply with the CUWSOP Clinical Instructor Expectations.

5. Complete the process for becoming a CUWSOP Clinical Instructor.
I work at this practice site at least 32 hours per week:
State of primary pharmacist license:
Other states with active pharmacist license:

1. Current Work Address and Information:

2. Academic Background:

3. Residency/Post Graduate Experience:

4. Past Work experience (for the past 5 years):

5. Additional training, certification or professional activities: (Please check all that apply)

6. Professional Organization memberships: (Please check all that apply)

7. Indicate all that apply to your current practice site:

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