COVID-19 Information

Voluntary Faculty Form

Request for appointment or reappointment in Clinical, Adjunct or Honorary Faculty Lines at the Geisel School of Medicine at Dartmouth

Visit the Academic Appointments, Promotions, and Titles website for criteria related to these two faculty lines.

All items must be completed by the applicant and reviewed by the Department Chair/Institute Director at Geisel before submitting this form to the Office of Faculty Affairs.

Appointments as Adjunct Faculty and Lecturers are for one academic year ending on June 30, or for the term of the course with which the faculty member is associated. Clinical and Honorary appointments are for two academic years ending on June 30. Appointments must be actively renewed for faculty status to continue. All rights and privileges associated with membership in the Geisel faculty terminate at the time of appointment termination.

Entries marked with * are required.

Name of faculty member*:

Department & Chair/Director*:

Current Employer and Job Title*:

Professional Degree(s)*:

This request is for*:

Required Information for New Appointments

Upload your CV:

SS #:

This information is required for personal identification, and is confidential.

Date of Birth:

This information is required for personal identification, and is confidential.

Most recent faculty title at Geisel or other academic institution.If unknown, put N/A

Dates*:

Institution*:

Title*:

Provide requested information below.Check all relevant boxes for which you have a named/designated faculty role (e.g., Instructor)

Medical Students:



MPH/MHCDS:



PhD, MS, certificate program:



Residency/Fellowship:



Grant/Proposal:


i.e., through Dartmouth College, D-H or Veranne in conjunction with a Geisel faculty member

Other pertinent information/roles:

Personal Information

Mailing Address*:

City*:

State*:

Zip*:

Preferred Email Address*:

Signature*:

NAME AND TITLE