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) Home Work
Home Address
Work Address
Preferred Telephone Number for College Business? (Please check) Home Work Cell Other
Home Telephone ( ) - Home Fax ( ) -
Work Telephone ( ) - Work Fax ( ) -
Cell Telephone ( ) - Other Telephone ( ) -
Preferred E-Mail Address for College Business? (Please check) NYMC Other
NYMC E-Mail Address
Other E-Mail Address
Please o Include o Exclude my Other E-Mail address from “Faculty Interactive” group postings.
Gender Male Female
Ethnicity American 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 origin Do not wish to respond
Current Citizenship US Resident Alien Non-Resident Visa (Visa Type )
Rev. 07/2015
Name:
EDUCATIONAL INFORMATION:
Undergraduate School
Degree Year of Graduation
Graduate School
Degree Year of Graduation
Honors/Awards
Medical School
Degree Year of Graduation
Honors/Awards
Residency Training
Specialty Dates
Sponsor
Specialty Dates
Sponsor
Fellowship Training
Specialty Dates
Sponsor
Specialty Dates
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. 07/2015
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 No If yes, please attach a complete explanation and return with this document to your NYMC chairman.
Alpha Omega Alpha Membership
Yes No If 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 Member Date
Please return this document with a copy of your current Curriculum Vitae.
-3- Rev. 07/2015
New York Medical College
School of Medicine
Tenure Appointment and Promotion Application
Candidate: Name:
(First) (Middle) (Last)
Degree: Other Degree: ______
Affiliation: NYMC WMC Metropolitan St. Joseph’s Brookdale St. Michael’s Other
Work Address:
Work Telephone ( ) - Work Fax ( ) -
Email Address: ______
Primary Department: Choose an item. Division: Choose an item.
Current Rank: Choose an item.
Proposed Rank: _Choose an item.
Status: Choose an item.
Track Requested: _Choose an item.
Tenure Proposed: Choose an item.
Secondary Department: Choose an item. Division: Choose an item.
Current Rank: Choose an item.
Proposed Rank: _Choose an item.
Status: Choose an item.
Track Requested: _Choose an item.
Tenure Proposed: Choose an item.
Tertiary Department: Choose an item. Division: Choose an item.
Current Rank: Choose an item.
Proposed Rank: _Choose an item.
Status: Choose an item.
Track Requested: _Choose an item.
Tenure Proposed: Choose an item.
NYMC Chairman Signature:______Date:______
Secondary Chair Signature:______Tertiary Chair Signature:______
Dean Signature: ______Date:______
Please return this form along with required Tenure, Appointment and Promotion paperwork to Barbara Donnadio, TAP Secretary, Sunshine Administration, Room #141. For assistance please call Barbara Donnadio at 914-594-3968 or email: . Be sure to include the following documents: You may access all guidelines, criteria and forms online at: www.nymc.edu/Academics/Faculty/InformationForFaculty
□ Tenure, Appointment/Promotion Application completed and signed.
□ Letter from Chairperson
□ Candidate Curriculum Vitae (following NYMC format)
□ Reference List: three outside NYMC community and two within NYMC.
□ Publications: a copy of three of your most significant/recent publications. -4-
Name:
FOR FACULTY RECORDS OFFICE USE ONLY
EMPLID: ______Created Modified
Date File Created/Modified:
ABMS: Verified N/A
OPMC: No Match Match N/A
License Verification in the following State(s):
-5- Rev. 01/2015