Affiliate/Volunteer Faculty Application

Thank you for your interest in joining NSU's New M.D. College. To begin the appointment process, please complete the below application and include the supporting documents.

Upon receipt of your online form, the Office of Faculty Affairs will review your application and contact you to discuss your involvement. Please direct questions to Stefanie Carter, Ed.D., at mdfacultyaffairs@nova.edu.

We appreciate your enthusiasm and support to NSU's M.D. College!

Please note: All fields marked with a * are required. All other fields are optional.

First Name

Middle Name

Last Name

Direct Phone Number

Fax

Address

Street

Apt/Suite/Etc.

City/Town

State

Zip/Postal Code

Degree*

M.D.

D.O.

Ph.D.

Ed.D.

J.D.

Other

Other Degree

Specialty

Subspecialty

Details

Hospital Affiliation

Do you have an active medical license?

Medical License Number(s)

Are you involved in any clinical trials?

Clinical Trial Details

Are you currently practicing?

Have you ever pled guilty or "no contest" to a crime, been convicted of a crime, had adjudication withheld and/or prosecution deferred?

Comments Please include timeline and details of issue(s).

Are you the subject of any investigation or proceeding that could result in your exclusion from participating for any length of time in any state or federally funded government health care program, including but not limited to Medicare and/or Medicaid?

Comments Please include timeline and details of issue(s).

Has your medical license been suspended, restricted, revoked, or surrendered?

Comments Please include timeline and details of issue(s).

Address

Street

Apt/Suite/Etc.

City/Town

State

Zip/Postal Code

Below are different ways in which faculty can be involved with the Nova Southeastern University's new M.D. college. Please select all that apply and explain your desired involvement.

Preceptor for a required clinical clerkship (3-4 week rotations)

Host students for an elective rotation

Pre-clinical preceptor, one afternoon (half day) a week

Mentor or advise students interested in your specialty

Teach advanced clinical skills related to your specialty

Give lectures on your clinical discipline during the pre-clerkship curriculum

Provide anonymous (HIPAA compliant) patient case files from which case studies will be developed for our curriculum

Collaborate with students on service learning projects

Collaborate with students on research projects or allow access to anonymous (HIPAA compliant) data

Serve on NSU MD committees (telecommuting available)

Present at special events or CME activities

Collaborate on physician directed quality improvement initiatives designed to improve the health of our community

Support NSU MD and/or its students through philanthropy

Comments Please enter any other interests not listed above and/or any additional comments

Please upload your Government ID (Driver's license or passport) and C.V. should include your telephone number, email address, current employment status, related work/academic status, and hospital affiliation. For clinicians, verification of FL medical license information and/or board certification should be included (if applicable).

Curriculum Vitae Microsoft Word or Adobe PDF

Government ID Microsoft Word or Adobe PDF

Medical Board Certifications Microsoft Word or Adobe PDF

Medicine License Microsoft Word or Adobe PDF

I attest that the information provided on my C.V. and any applications pertinent to this process are true and contain correct information to the best of my knowledge.

Note: NSU is an affirmative action/equal opportunity institution.

Applicant Information

Address

Degree*

Affiliation/Practice Information

Address

Desired Involvement