UNIVERSITY
NAME:
of
PENNSYLVANIA
-- REQUEST FOR APPROVAL (PART I)
Date:
____ Citizenship:
USA
Other (specify)
Visa Type
John S. Doe, M.D.
The reappointment of Dr. John S. Doe as Assistant Professor of Clinical (Please fill in the name of your
Department) in the Associated Faculty of the Perelman School of Medicine for three years effective July 1,
2005 (full salary; not in tenure probationary status in this appointment).
Proposed by:
Approved by:
School
Perelman School of Medicine
Department
(Please fill in the name of your Department)
Committee on Appointments and Promotions, Perelman School of Medicine __________________________
Standing Committee of Departmental Chairmen _________________________________________________
Forwarded by: Dean or Dean's Representative _______________________________________
PRESENT POSITION:
Dates:
Date: ________________
(Leave blank for persons not presently affiliated with the University of Pennsylvania)
7/1/02-6/30/05
Title:
Assistant Professor of Clinical (Please fill in the name
of your Department)
Faculty Status:
Salary Status:
____ Salary Source:
Standing Faculty
Full Salary
Dept. budget A-2
A-1 budget
Tenure Status: (with dates)
Associated Faculty
Partial Salary
Grant(s)
Other (specify)
No Salary
Clinical Group
Not in tenure probationary status in this appointment.
PROPOSED POSITION:
Dates:
7/1/05-6/30/08
Faculty Status:
Salary Status:
____ Salary Source:
Assistant Professor of Clinical (Please fill in the name of your
Title: Department)
Standing Faculty
Full Salary
Dept. budget A-2
A-1 budget
X
Tenure Status: (with dates)
X
Associated Faculty
Partial Salary
Grant(s)
Other (specify)
No Salary
Clinical Group
Not in tenure probationary status in this appointment.
FACULTY APPOINTMENT HISTORY: (at the University of Pennsylvania)
Dates
7/1/02-6/30/05
PSC ACTION TAKEN:
Approved
Other
Title and Department
Affiliation/Salary Status
Assistant Professor of Clinical (Please fill in the name of your Department) F/F
Date of Provost’s Staff Conference:
Not Approved
Conditionally Approved