Form 08-4228a - Certification Of Preceptorship
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1State of Alaska
Department of Community and Economic Development
Division of Occupational Licensing
Board of Certified Direct-Entry Midwives
P.O. Box 110806
Juneau, Alaska 99811-0806
(907) 465-2580
E-mail: license@dced.ak.us
CERTIFICATION OF PRECEPTORSHIP
The following section needs to be completed by the applicant's preceptor. (NOTE: If an applicant has more than
one preceptor, please make photocopies and submit with the application.)
I,
, have been practicing for
year(s) and certify that
will be serving her/his
apprenticeship under my direction.
Signature of Preceptor
Alaska Certification Number
(If applicable)
SUBSCRIBED AND SWORN TO before me, a Notary Public in and for the state of
,
this
day of
, _________.
Notary Public
SEAL
My Commission Expires:
08-4228a (Rev. 11/99)
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