Department of MedicineWithout Salary Appointment Request

Department of Medicine

Without Salary Appointment Request

Your Email Address:*

Are you requesting a new appointment or terminating an existing appointment?*

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Terminations

Are you requesting termination of an adjunct appointment, affiliate appointment, or community instructor?*

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New Appointment

Affiliate Appointment

Adjunct Appointment

Community Instructor Appointment

Candidate's Primary Site:*

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Candidate's Division:*

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Candidate's First Name:*

Candidate's Last Name:*

What is the effective date of the termination?*

What is the reason for terminating the appointment?*

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Is the faculty member leaving to work at one of these affiliate sites?*

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Affiliate, Adjunct or Community Instructor:*

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Candidate's Email Address:*

not @UMN.EDU. This would be an alternative contact email.

Candidate's Phone Number:*

Candidate's Work Mailing Address:*

Candidate's Degree:*

Requested Rank:*

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Requested Track:*

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Candidate's Mentor:*

Name of academic mentor (or committee)

Candidate's Date of Birth:*

Candidate's Racial Group (check all that apply):*

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Candidate's Gender:*

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Candidate's UMN Employee ID (if they have one- optional):

Candidate's Effective Date of New:*

Candidate's Responsibilities Involving University of Minnesota:*

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File Upload*

Required for Affiliate: WOS Appointment Request Memo - Academic Development Plan - Curriculum Vitae (CV) - Additional Materials (Optional)

Required for Adjunct: Adjunct Appointment Request Memo - Curriculum Vitae (CV) - Additional Materials (Optional)

Required for Community Instructor: Letter of Recommendation (signed by clerkship director, site director, course director, or department head)

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