Clinical Adjunct Professor Status Appointment Application In accordance with the process for Status Appointment applications, please fill in and submit the information below. The Office for Clinical Education will review your application and forward you confirmation by mail. If you have any questions, please e-mail email@example.com or call (416) 596 3101 ext. 3328Part I - Clinical Adjunct Professor InformationName * Required Mr.Mrs.Ms.Dr.Prof. Prefix First Last Clinical Site * Required Address * Required Street Address Address Line 2 City Province / State / Region Postal Code / Zip AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Position * Required Department Email * Required Phone * RequiredFaxProfessional Certification(s) * Required Michener Program * RequiredAnesthesia AssistantCardiovascular PerfusionChiropodyDiagnostic CytologyGenetics TechnologyImaging InformaticsMagnetic Resonance ImagingMedical Laboratory SciencesNuclear Medicine & Molecular Imaging TechnologyRadiation TherapyRadiological TechnologyRespiratory TherapyUltrasoundPart II - AcknowledgementIf granted, I recognize and agree to fulfill the responsibilities required by the status-only appointment as Clinical Adjunct Professor: Contribution to advances in scope of practice and in the broader health care context Serve as role model and mentor to colleagues and students alike Create a positive learning environment for students Completion of an Annual Progress Report to maintain the status appointment as Clinical Adjunct Professor * Required I agree. Date - must be mm/dd/yyyy format * Required MM slash DD slash YYYY Please check this box only if you do not grant permission to have your name and/or photograph published in future Michener publications and on the Michener website. I do not grant permission Part III - Criteria for Status AppointmentHow many years of professional practice do you have? * RequiredWhat previous and/or current Michener status appointments do you hold? * RequiredWhat management role do you play in your institution? * RequiredPart IV - Demonstrated ContributionsTo be considered for the status appointment of Clinical Adjunct Professor, you must have demonstrated contributions to at least one of the following criteria. Please describe your contributions in detail in the space below, and include supporting documentation to validate your contributions. Research/Creative Professional Activity (i.e. scholarly writing, presentations, and/or research grants) Sustained Academic Excellence (i.e. documented excellence in teaching, educational or curricular development, or educational administration) Outstanding Contribution / Support to Michener (i.e. Program Advisory Committee involvement, Alumni involvement)Please describe your contributions in detail: * RequiredAdditional documentation to be submitted with this application:Recent curriculum vitae * RequiredMax. file size: 2 MB.