Professional Adjunct Professor Application
School of Occupational Therapy Dalhousie University
Name
First Name
Last Name
Primary affiliation (university/workplace)
Primary affiliation website, if applicable
Contact Information
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Information required for Dalhousie Identification Number (Banner ID)
Social Insurance Number
Birthdate
-
Month
-
Day
Year
Date
Academic and/or Professional Background
Occupational Therapy Degree and year of graduation (if applicable)
Other Academic Degree(s) (if applicable)
Other Education, Background, Expertise (e.g., academic research interests, practice interests, populations of interest)
Describe your past contributions and collaborations with the School (past 5-years). Note: The application should confirm at least three successful terms of contributions to student education within a five-year period.
Research student advising; thesis committee work Note: To supervise graduate students, an application must be submitted for Adjunct Appointment with the Faculty of Graduate Studies. Please discuss this process with the student supervisor.
Support student research course projects
Unpaid teaching in courses or lectures
Provincial Fieldwork Education Coordinator or Liaison with the School
Fieldwork education preceptor with the School (attach proof of professional licensure)
Unpaid support of classroom education (e.g., tutor, teaching assistant, OSCE facilitation)
Other text
Please check ONE box about consent below.
I consent to having my name and appointment information listed on School information materials.
I do not consent to having my name and appointment information listed on School information materials.
Signed commitment to making contributions as an Adjunct Professor:I understand that an Adjunct Professor Appointment requires me to contribute in at least 1 method from the ‘potential contributions’ list above, or another substantial contribution.I understand that renewal will involve completion of a renewal application and confirmation of contributions during the previous appointment. Renewal is not automatic and I be may required to self-report my contributions to the Director for consideration of renewal.
Date
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Month
-
Day
Year
Date
Please upload your Letter of interest (with contact information)
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Please upload a current CV Note: Occupational therapy preceptors must attach proof of professional licensure.
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