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. Approval of the candidate’s application and credentials by the Department Chair/Institute Director is required for the voluntary faculty appointment to be granted.

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:	required course/clerkship nonrequired course
MPH/MHCDS:	required course/clerkship nonrequired course
PhD, MS, certificate program:	required course/clerkship nonrequired course
Residency/Fellowship:	required course/clerkship nonrequired course
Grant/Proposal:	Key personnel on funded or submitted grant/proposal at Geisel 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