Clinical Adjunct Faculty Application

Contact:
Kari Hoskins, Credentialing Coordinator
LMU-DCOM Osteopathic Medicine Program
Phone: 423-869-7406
Fax: 423-869-7078
Email: kari.hoskins@LMUnet.edu
 
All information contained in this form will remain confidential.
 
Please submit the following with this application (Applications cannot be processed until all documents below have been submitted)
  • Current typed CV
  • Copy of current license
  • Board Certification, if applicable
  • Downloadable W-9 form attached at end of the application (for compensation to which you may be entitled)

TO:  Kari Hoskins, Credentialing Coordinator
via Email: kari.hoskins@LMUnet.edu
or  Fax: 423-869-7078
or  Mail: LMU-DCOM, 6965 Cumberland Gap Parkway, Harrogate, TN  37752

 
 
 

For CME reporting purposes

Check all that apply

Check all that apply

I agree to accept a minimum of 2 students during the 3-year appointment period, if requested.

I agree to accept a minimum of 2 students during the 3-year appointment period, if requested.

I agree to provide at least 2 on-campus presentations during the 3-year appointment period, if requested.

I certify by typing or signing my name above that all statements in this application are true and complete. I authorize administrative official of the Lincoln Memorial University – DeBusk College of Osteopathic Medicine to make inquiries necessary to verify my professional qualifications, my adherence to the professionalism standards of my profession, my reputation and ability to teach and appropriately work with medical and/or physician assistant students.

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W-9 form.pdf107.83 KB