NEW YORK MEDICAL COLLEGE



40 Sunshine Cottage Road Valhalla, New York 10595 Tel 914-594-4523 Fax 914-594-4565 faculty_records @nymc.eduOffice of Faculty RecordsRECOMMENDATION FOR NYMC FACULTY APPOINTMENT/PROMOTIONSECTION I – TO BE COMPLETED BY PROPOSED FACULTY MEMBERPERSONAL INFORMATION:Name(First)(Middle)(Last)Soc. Sec. #--Date of Birth // (Mo) (Day) (Yr)Preferred Mailing Address for College Business? (Please check) FORMCHECKBOX Home FORMCHECKBOX WorkHome AddressWork Address Preferred Telephone Number for College Business? (Please check) FORMCHECKBOX Home FORMCHECKBOX Work FORMCHECKBOX Cell FORMCHECKBOX OtherHome Telephone()- Home Fax ()-Work Telephone()- Work Fax()-Cell Telephone()-Other Telephone()-Preferred E-Mail Address for College Business? (Please check) FORMCHECKBOX NYMC FORMCHECKBOX OtherNYMC E-Mail AddressOther E-Mail AddressPlease ? Include ? Exclude my Other E-Mail address from “Faculty Interactive” group postings.Gender FORMCHECKBOX Male FORMCHECKBOX FemaleEthnicity FORMCHECKBOX American Indian or Alaskan Native FORMCHECKBOX Mexican American or Chicano (Hispanic) FORMCHECKBOX Asian or Pacific Islander FORMCHECKBOX Puerto Rican (Hispanic) FORMCHECKBOX Black, not of Hispanic origin FORMCHECKBOX Other Hispanic FORMCHECKBOX White, not of Hispanic origin FORMCHECKBOX Do not wish to respondCurrent Citizenship FORMCHECKBOX US FORMCHECKBOX Resident Alien FORMCHECKBOX Non-Resident Visa (Visa Type )Rev. 07/2015 Name: EDUCATIONAL INFORMATION:Undergraduate SchoolDegreeYear of GraduationGraduate SchoolDegreeYear of GraduationHonors/Awards Medical SchoolDegreeYear of GraduationHonors/Awards Residency TrainingSpecialtyDates SponsorSpecialtyDates SponsorFellowship TrainingSpecialtyDates SponsorSpecialtyDatesSponsorCurrent Diplomate of: Medical Specialty: Expiration Date MERGEFIELD Diplomate_Specialty_Year1 MOC FORMCHECKBOX Subspecialty: Expiration Date MERGEFIELD Diplomate_Specialty_Year1 MOC FORMCHECKBOX Subspecialty: Expiration Date MERGEFIELD Diplomate_Specialty_Year1 MOC FORMCHECKBOX Current Diplomate of: Medical Specialty: Expiration Date MERGEFIELD Diplomate_Specialty_Year1 MOC FORMCHECKBOX Subspecialty: Expiration Date MERGEFIELD Diplomate_Specialty_Year1 MOC FORMCHECKBOX Subspecialty: Expiration Date MERGEFIELD Diplomate_Specialty_Year1 MOC FORMCHECKBOX -2-Rev. 07/2015 Name: Current LicentiatesState / 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 chairman.Alpha Omega Alpha MembershipYes 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 AppointmentsTitle Department Facility Dates of Service Title Department Facility Dates of Service Honors/AwardsProfessional 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 MemberDatePlease return this document with a copy of your current Curriculum Vitae.-3-Rev. 07/2015New York Medical CollegeSchool of MedicineTenure Appointment and Promotion ApplicationCandidate: Name: (First)(Middle)(Last)Degree: Other Degree: ______________________Affiliation: FORMCHECKBOX ?NYMC FORMCHECKBOX WMC FORMCHECKBOX Metropolitan FORMCHECKBOX St. Joseph’s FORMCHECKBOX Brookdale FORMCHECKBOX St. Michael’s FORMCHECKBOX OtherWork 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: Barbra_Donnadio@nymc.edu. Be sure to include the following documents: You may access all guidelines, criteria and forms online at: nymc.edu/Academics/Faculty/InformationForFacultyTenure, Appointment/Promotion Application completed and signed.Letter from ChairpersonCandidate 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 ONLYEMPLID: ____________ FORMCHECKBOX Created FORMCHECKBOX ModifiedDate File Created/Modified:ABMS: VerifiedN/AOPMC:No MatchMatchN/ALicense Verification in the following State(s): -5-Rev. 01/2015 ................
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