Get Preceptor Application - State Of Indiana - In

Completing the Preceptor Application for the State of Indiana is essential for individuals seeking to become preceptors in health facility administration. This guide offers clear, step-by-step instructions to ensure users can successfully fill out the application online.

Follow the steps to complete your application.

1. Click ‘Get Form’ button to access the Preceptor Application and open the form in your document editor.
2. Begin by providing your applicant information in the designated fields including your full name, social security number, residential address, email address, city, state, ZIP code, daytime telephone number, date of birth, birthplace, HFA license number, original issuance date, training facility name, expiration date, facility telephone number, and facility address.
3. In the administrator-in-training information section, fill in the name and address of the administrator-in-training, ensuring accuracy in city, state, and ZIP code.
4. List your work experience for the past three years, stating your employer, position, type of business, duration of employment, duties, type of facility, and the number of beds in each facility. Use clear, concise bullet points for easier reading.
5. Provide any other relevant work experience in health facility administration or related fields in the specified area.
6. Answer the questions about previous qualifications and any disciplinary issues honestly. If you answer 'yes' to any question, prepare a sworn affidavit detailing the circumstances.
7. Complete the verification section by swearing or affirming that your statements are true. Remember to include your signature and date at the bottom of the form.
8. After filling in all required fields, review the form for accuracy. Users can then save changes, download the completed application, print it for submission, or share it as necessary.

Complete your Preceptor Application online today to ensure a smooth submission process.