Directory Information for Adjunct Faculty

Please provide the CONHI Dean's Office the following information for our records.

Personal Information
First Name *
Middle Name
Last Name *
Gender

Gender Female Male
Date of Birth Date of Birth * / MM / DD YYYY
Home / Physical Address Home / Physical Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Primary Email *
Secondary Email
Primary Phone Primary Phone * - ### - ### ####
Primary Phone Type *

Primary Phone Type Mobile / Cell Landline Other
Secondary Phone Secondary Phone - ### - ### ####
About Library Resources
Would you like UTA Library Access? *

Would you like UTA Library Access? Yes, please arrange for me to have access to the UTA Library. No, I will not need access to the UTA Library.
Employment Information
Your Place of Employment *
Your Title at Your Place of Employment *
Your Area(s) of Specialization
Address of Your Place of Employment Address of Your Place of Employment
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
For which program are you a preceptor? *

For which program are you a preceptor? MSN - Adult Gerontology Acute Care Nurse Practitioner MSN - Adult Gerontology Primary Care Nurse Practitioner MSN - Education MSN - Family Nurse Practitioner MSN - Neonatal MSN - Pediatric Acute Care Nurse Practitioner MSN - Pediatric Primary Care Nurse Practitioner MSN - Psychiatric Nurse Practitioner
Comments
Comments