Reappointment Adjunct Application

Complete this form to reapply for your adjunct appointment within UNC PM&R. Please complete this form ONLY if you have a current adjunct appointment within UNC PM&R. If you have never had an adjunct appointment within our department, please use the "Initial Adjunct Appointment" form instead.

Applicant Information
Today's Date MM/DD/YYYY*
Full Legal Name*

First, Middle, and Last Legal Names
Degrees*

MD, PhD, MS, etc.
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
Current Position at Place of Employment*

Your current job title
Address of Place of Employment*

Street, City, State, and Postal Code
Summary of Contributions to the UNC Department of PM&R
Below you will find a listing of our department’s meaningful activities. Please document the activities that you have participated in since being granted your adjunct appointment with UNC PM&R.
Taught medical students and residents at UNC PM&R, during your current appointment*
Please provide number of students, learning topics, and frequency of your teaching. If you did not teach, please write "no."
Supervised a medical student or resident's clinical work at UNC PM&R, during your current appointment*
Please provide details of clinical work involved and time spent. If you did not supervise a medical student or resident, please write "no."
Collaborated on Research through grants or papers within UNC PM&R, during your current appointment*
Please provide name of the research project, other involved faculty members, and time spent. If you did not collaborate on research through grants or papers, write "no."
Served as a consultant on any research project within UNC PM&R, during your current appointment*
Please provide your consulting details, other involved faculty members, and time spent. If you did not serve as a consultant on a research project, write "no."
Written Responses
Your statement*
Write a brief statement (3-7 sentences) as to how your UNC PM&R Adjunct Appointment has served you.
Engagement*
If granted a reappointment within our department, are there other ways that you plan to engage with our department over the next two years? If so, please describe. If no, please write "none."
CV Upload
Max. file size: 100 MB.
Please attach a copy of your latest Curriculum Vitae ("CV") completed in the UNC School of Medicine format.

Reappointment Adjunct Application

Reappointment Adjunct Application

Applicant Information

Summary of Contributions to the UNC Department of PM&R

Written Responses