Additional Preceptor Application
Instructions for completing this form:
In order to ensure accurate and complete information, this PDF fillable form must be completed electronically by typing in the information in
the appropriate fields. Once all the information is filled in, you should then print the form,sign and submit it.
By completing and submitting this application, I agree to act as a preceptor at the facility named below. I have
reviewed the information on the VTDLP website at the link below and agree to perform the required duties.
https://www.sanjuancollege.edu/school-of-trades-and-technology/programs/veterinary-technology/clinical-requirements/
Facility Information
FACILITY
ADDRESS
CITY
I
STATE
I I
Zip Code
I
FACILITY PHONE
I
FACILITY FAX
I
Student Information
List the full name(s) of all San Juan College Veterinary Technology student(s) for whom you will be acting as preceptor. Please
note that once approved, you will NOT be limited to only those students listed on this application and you will not be required
to reapply if future students join your approved facility.
0 0 0 0 0 0
Student #1 Student #3
Student #2 Student #4
Preceptor Information
First Name Middle Initial Last Name
Maiden or former name as may appear on license or diploma
Email Address
Daytime phone Type
Indicate your credentials below
DVM VMD CVT RVT LVT
Graduate of AVMA approved
Vet Tech Program
IMPORTANT: All Veterinary Technicians MUST provide a current
copy of state licensure or copy of a diploma from an AVMA approved
veterinary technician program. Applications submitted without proof
of credentials will NOT be approved.
Signature of Preceptor Applicant (original signature required) Date
Print, sign and date this form and return via fax (505-566-3570), email (painterc@sanjuancollege.edu) or mail to
San Juan College, Veterinary Technology Program, 4601 College Blvd., Farmington, NM 87402
Do not print this
form until all
required fields
have been filled in
electronically
click to sign
signature
click to edit
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