Clinical Site Letter of Intent

Preceptor Information

Name(Required)

First Last

Email(Required)

Phone Number(Required)

Title(Required)

For MD/DO, do you currently hold board certification?(Required)

Yes

If no, have you previously held board certification(Required)

Yes

What is the certifying body?(Required)

Optional. Please upload a copy of your certification letter/card/certificate here

Max. file size: 49 MB.

For PAs, are you currently NCCPA certified?(Required)

Yes

If no, have you previously been NCCPA certified?(Required)

Yes

What is you NCCPA Number?(Required)

For NPs, do you currently have or previously held board certification? (ANCC, AANPCB, AACN, PNCB, NCC)(Required)

Yes

Please upload a copy of your certification letter/card/certificate

Drop files here or

Max. file size: 49 MB.

If other please write here:(Required)

Please upload CV(Required)

Max. file size: 49 MB.

Clinical Site Information

Contact Person(Required)

First Last

Contact Person Phone Number(Required)

Contact Person Email(Required)

Clinic/Practice Name(Required)

Clinic/Practice Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website

Is the practice in a rural or underserved area?(Required)

Yes

Affiliation Agreement Information

Signatory Name (who may legally sign the Affiliation Agreement for your facility)(Required)

Signatory Email(Required)

Organization/Facility Name(Required)

Rotation/Setting Information

Rotation Discipline(Required)

Number of PA students you are willing to precept per year:(Required)

Please enter a number less than or equal to 99.

Please select all settings that apply for rotation(Required)

Inpatient

Outpatient

Emergency Room

Operating Room

Does your practice use telehealth/telemedicine?(Required)

Yes

If yes, what percentage of this rotation's patient care would be via telehealth/telemedicine?

Preferred Months for Precepting

Electronic Signature

This signed form signifies the intent to participate in the clinical education of Elon University Physician Assistant Program in Charlotte students. Exact rotation dates to be determined.

Type Your Full Name Here*(Required)

By entering my full name and submitting this form, I certify that the information provided is accurate and complete to the best of my knowledge. I understand that my typed name serves as my electronic signature. By signing this document I authorize all information to be used for the Elon University Physician Assistant Program in Charlotte and consent this as my electronic signature.

Date Signed(Required)

The Elon University Physician Assistant (PA) Program in Charlotte has applied for Accreditation-Provisional from the Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The Elon University Physician Assistant (PA) Program in Charlotte anticipates matriculating its first class in January 2027, pending achieving Accreditation-Provisional status at the September 2026 ARC-PA meeting. Accreditation-Provisional is an accreditation status granted when the plans and resource allocation, if fully implemented as planned, of a proposed program that has not yet enrolled students appear to demonstrate the program’s ability to meet the ARC-PA Standards or when a program holding accreditation-provisional status appears to demonstrate continued progress in complying with the Standards as it prepares for the graduation of the first class (cohort) of students. Please note that the program will not commence in the event that the provisional accreditation is not received.

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Elon University PA Program in Charlotte Clinical Site Letter of Intent

Preceptor Information

Clinical Site Information

Affiliation Agreement Information

Rotation/Setting Information

Electronic Signature