Office of Population Health Improvement (OPHI)
Maryland Income Tax Credit for Preceptors in Health Care Workforce Shortages AreasApplication for Tax Credit CertificateApplication Period: December 20 – January 12Part 2Proof of Student Attendance (Preceptor must type and submit)This document should be completed by the preceptor Applicant Name:___________________________________________________________ Date:______________________________________Name of StudentType of StudentSchool NameTime FrameTotal Hours 1. 2.3.4.5.6.7.8.9.10.Please return this application form to:Workforce CoordinatorOffice of Population Health ImprovementMaryland Department of Health201 West Preston StreetBaltimore, MD 21201Phone: 410-767-7141 ● Fax: 410-333-7501Email: mdh.providerworkforceprograms@ ................
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