Full Legal Name*
First, Middle, and Last Legal Names
Licenses*
Medical or other. If none, please write "none."
Certifications*
If none, please write "none."
Email Address*
Your preferred email address
Phone Number*
Your preferred phone number
Home Address*
Street, City, State, and Postal Code
Current Place of Employment*
Current Place of Employment
Address of Place of Employment*
Street, City, State, and Postal Code
Teaching medical students and residents at UNC PM&R*
If you have done this in the past, please provide number of students, learning topics, and frequency. If you plan to do this in the future, please describe your future teaching plans. If you do not plan to teach, please write "no."
Supervise a medical student or resident's clinical work at UNC PM&R.*
If you have done this in the past, please provide details of clinical work involved and time spent. If you plan to do this in the future, please describe your future supervision plans. If you do not plan to supervise, please write "no."
Collaborate on Research through grants or papers within UNC PM&R.*
If you have done this in the past, please provide name of the research project, other involved faculty members, and time spent. If you plan to do this in the future, please provide the name of the research project, other involved faculty, and expected time spent. If you do not plan to collaborate on research through grants or papers, write "no."
Serve as a consultant on any research project within UNC PM&R*
If you have done this in the past, please provide your consulting details, other involved faculty members, and time spent. If you plan to do this in the future, please provide the consulting details, other involved faculty, and expected time spent. If you do not plan to serve as a consultant on a research project, write "no."
Your statement*
Write a brief statement (3-5 sentences) as to how your UNC PM&R Adjunct Appointment will serve you.
Engagement*
If granted an Adjunct Appointment, are there other ways that you plan to engage with UNC PM&R over the next two years? If so, please describe. If no, please write "none."
