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We are excited that you are interested in the NCPC Faculty Development Program. Please review the objectives of each program module and then fill out the following form to apply.

In order to provide information to our program graduates in the future and to remain abreast of their career needs and progress, we try to maintain updated contact information. Please provide a phone number, email, and mailing address through which you can be reached for the foreseeable future.

Fields marked with an * are required

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Personal Information

*First Name

*Last Name

*Email Address (Personal)

*Email Address (Work)

*Profession

*Area of Specialty (if applicable)

*Cell Phone

Office Phone

*Personal Mailing Address

Address 2

*City

State

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*Zip Code

Faculty Development Program Information

1. Why are you interested in the Faculty Development Program?

2. What specific knowledge or skills do you hope to gain?

3. What are your long-term career goals and interests?

*4. How did you hear about the Faculty Development Program?

5. Do you have publication experience in a Peer-Reviewed Journal? If so, please provide a list of citations

Position Information

Do you currently have a faculty appointment?

YesNo

If yes, which department?

If no, what is your position?

Which of the following best describes your practice?

AcademicPrivateGroupCommunity Health CenterHospital BasedManaged CareOther (please describe)

If other, please enter practice description

Are you currently teaching students or residents?

Yes, Part-TimeYes, Full-TimeNo

If yes, how many hours per week do you teach on the average?

How likely are you to become a Full-Time teacher in the next five years?

Highly UnlikelyNot LikelyNeutralLikelyHighly Likely

How likely are you to become a Part-Time teacher in the next five years?

Highly UnlikelyNot LikelyNeutralLikelyHighly Likely

Check the name of any programs you are enrolled in:

Yearlong/Modular Faculty Development Program

Communication Preference

How do you prefer to receive information?

EmailPhoneText

*Your Signature (typed)

*Date

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Pre-& Post-Assessment Surveys

Pre and post assessments are a requirement in the course, to receive full credit for participation. Pre-assessments will be delivered via email once you apply to the program. Post assessments will be completed prior to the end of each class. These assessments are an integral part of improving the quality of the program.