New York Medical College

40 Sunshine Cottage Road Valhalla, New York 10595 Tel 914-594-4523 Fax 914-594-4565 faculty_records @nymc.edu

Office of Faculty Records

RECOMMENDATION FOR NYMC FACULTY APPOINTMENT/PROMOTION

SECTION I – TO BE COMPLETED BY PROPOSED FACULTY MEMBER

PERSONAL INFORMATION:

Name

(First)(Middle)(Last)

Soc. Sec. #--Date of Birth //

(Mo) (Day) (Yr)

Preferred Mailing Address for College Business?(Please check)HomeWork

Home Address

Work Address

Preferred Telephone Number for College Business? (Please check)HomeWorkCell Other

Home Telephone()- Home Fax ()-

Work Telephone()- Work Fax()-

Cell Telephone()-Other Telephone()-

Preferred E-Mail Address for College Business?(Please check)NYMCOther

NYMC E-Mail Address

Other E-Mail Address

Please Include Exclude my Other E-Mail address from “Faculty Interactive” group postings.

Gender MaleFemale

EthnicityAmerican Indian or Alaskan Native Mexican American or Chicano (Hispanic)

Asian or Pacific Islander Puerto Rican (Hispanic)

Black, not of Hispanic origin Other Hispanic

White, not of Hispanic originDo not wish to respond

Current CitizenshipUSResident AlienNon-Resident Visa (Visa Type )

Rev. 07/2015a

Name:

EDUCATIONAL INFORMATION:

UndergraduateSchool

DegreeYear of Graduation

GraduateSchool

DegreeYear of Graduation

Honors/Awards

MedicalSchool

DegreeYear of Graduation

Honors/Awards

Residency Training

SpecialtyDates

Sponsor

SpecialtyDates

Sponsor

Fellowship Training

SpecialtyDates

Sponsor

SpecialtyDates

Sponsor

Current Diplomate of:

Medical Specialty: Expiration Date MOC

Subspecialty: Expiration Date MOC

Subspecialty: Expiration Date MOC

Current Diplomate of:

Medical Specialty: Expiration Date MOC

Subspecialty: Expiration Date MOC

Subspecialty: Expiration Date MOC

-2-Rev. 07/2015a

Name:

Current Licentiates

State/ Number Initial Year Granted Expiration Date

State / Number Initial Year Granted Expiration Date

Are you now, or have you ever been, the subject of a professional conduct inquiry, investigation or proceeding?

Yes NoIf yes, please attach a complete explanation and return with this document to your NYMC chair.

Alpha Omega Alpha Membership

Yes NoIf yes, indicate: Associated School:

Designation*: Year of Election:

* i.e., “student”, “house officer”, “alumnus”, or “faculty initiate”

PROFESSIONAL APPOINTMENTS AND ACTIVITIES:

Current and/or Previous Academic Appointments

Title Department

Institution Dates of Service

Title Department

Institution Dates of Service

Current and/or Previous Hospital Appointments

Title Department

Facility Dates of Service

Title Department

Facility Dates of Service

Honors/Awards

Professional Activities (e.g. organized medical/professional societies, etc.)

I certify to the best of my knowledge that the information provided above is true.

Signature of Faculty/Proposed Faculty MemberDate

Please return this document with a copy of your current Curriculum Vitae to your Department Chair.

-3-Rev. 07/2015a

SECTION II – RECOMMENDATION OF CHAIR

(To be completed by NYMC Chair)

Name of Faculty/Proposed Faculty Member:

Proposed Faculty Appointment:Primary SecondaryTertiary

in Department of:

Type of Request:Appointment at Proposed Title:

Promotion

Current Title:

Proposed Title:

NYMC Faculty Status: Full-Time Part-Time Voluntary

If FT, is tenure being recommended?YesNo

If FT or PT, indicate payroll status (i.e., paid by):AffiliateFaculty PracticeNYMC

Assigned Responsibilities:

Teaching

Students in

MedicalSchoolBasic Medical SciencesHealth Sciences

Residents/Fellows

Continuing Medical Education

Research

Type:Basic ScienceClinical

Other (please specify)

Patient Care

Practice Setting:Faculty PracticePrivate Practice

Other Setting (please specify)

Activity Site/Affiliate Designation:

NYMC Basic Sciences Department

Hospital (please identify)

Division/Section(please identify)

Community-Based Physician/Primary Care Preceptor

Other(please specify)

-4-Rev. 07/2015a

Name:

Signature of Hospital Chair/Date

Director of Service (if applicable)

Signature of Hospital Affiliate Dean (if applicable)Date

Recommended by NYMC ChairDate

Signature of DeanDate

FOR FACULTY RECORDS OFFICE USE ONLY

EMPLID: ______Created Modified

Date File Created/Modified:

ABMS: VerifiedN/A

OPMC:No MatchMatchN/A

License Verification in the following State(s):

Notes:

-5-Rev. 07/2015a