UNCSCHOOL OF MEDICINE CLINICAL FACULTY INFORMATION SHEET
Please complete ALLitems below. This will allow us to complete the all the paperwork, including a criminal background check, necessary for receiving a clinical appointment. Email completed forms, including a copy of your CV to . Completed forms will be sent to you for review and signature.
NAME (last, first, middle)
Please list all other names by which you have been know, along with the dates each name was used:
Name Dates
HOME ADDRESS
PROFESSIONAL ADDRESS
PHONE FAX E-MAIL ADDRESS
SOCIAL SECURITY # DATE OF BIRTH
BIRTHPLACE (City, State, County)
(If other than USA include pertinent information, i.e. resident alien registration number)
CITIZENSHIP RACE SEX
EDUCATION:
Institution and LocationDegreeMajorYear Conferred
Baccalaureate
Masters (if any)
Doctoral
EMPLOYMENT:
Institution and LocationRank or TitleDates
Residency
Fellowship
Practice & Other
Current Position
Current Hospital or Other Institutional Appointments
LICENSURE:NC License # Other State (if applicable)
BOARD STATUS:
CertificationRecertificationIf not yet certified, check below
Dates Datesif "qualified" to take exam.
Primary Specialty
Subspecialty
Spouse or Relative Currently Employed by UNC-Chapel Hill:Yes (complete below) No
Name(s) of Relative(s)RelationshipRank/TitleDepartment
If you have worked outside North Carolina, please list the Sates, dates lived or worked in those locations, city, counties, and the name(s) used during those times
NameStateCounty City Dates
* PLEASE ATTACH YOUR CURRICULUM VITAE *
1) I authorize your use of my Social Security number for identification and funding purposes.
2) I hereby certify that all of the above information is accurate. I understand the employer is required by law to verify credentials and other qualifications. I hereby authorize the release to UNC-CH of any document or information that may serve to verify any of the above information.
Signature of Nominee Date