Full Academic Title Nomination Form

View the James Cook University (JCU) Adjunct Appointment Procedure

Nominee Details

Date of Birth *

Gender *

(e.g., Townsville University Hospital)

(if same as above leave blank)

Health Professional Registration

Please provide details of your health professional registration, including registration number and type of registration.

Registration Expiry date

Academic Title Request

Academic Title proposed/requested for teaching AND research appointments:

If you selected a College above, which is your preferred Discipline?

If you selected a College above, which is your preferred Discipline?

If you selected a College above, which is your preferred Discipline?

Involvement with JCU

Please outline your current involvement with the University and with whom at JCU your nomination has been discussed.
Note: This is a mandatory field for completion and will assist the Committee in their assessment of your nomination

Please briefly outline your proposed involvement with the University if you are successful in being awarded a full academic title.
Note: Eligibility Criteria for Full Academic Titleholders can be found at Section 5 of the James Cook University Adjunct Appointments Procedure.
Note: This is a mandatory field for completion and will assist the Committee in their assessment of your nomination.

Referees

Please provide details for three (3) referees, include their name, title, address, phone number and email address.

Note: Referees will be provided with a copy of your CV and nomination as required.

Note: Nominations for Associate Professor require one referee of national standing and one of international standing. Nominations for Professor require two referees of international standing.

Intellectual Property *

Other Information

Please feel free to include any other information that you believe may support your nomination.

Note: only enter additional information that does not appear in your CV

(max 50000 characters)

(max 50000 characters)

(max 50000 characters)

(max 50000 characters)

(max 50000 characters)

(max 50000 characters)

Required Attachments

  • Please attach your Curriculum Vitae (CV).
  • Please attach your registration certification.

(Maximum size: 2 MB )

(Maximum size: 2 MB )

(Maximum size: 5 MB, Please use a single ZIP file for multiple documents)

Insurance Declaration

If you will be delivering clinical services over the time that you intend to hold an Academic Title (normally 3 years from the time of award), please provide details of your medical malpractice insurance and attach evidence of insurance.

If you will be delivering clinical services solely in the capacity as a Queensland Health employee (and not for a private healthcare organisation or in the capacity as a private practitioner), please select yes below.  In this instance you will be indemnified by Queensland Health.

Declaration *

(Maximum size: 5 MB, Please use a single ZIP file for multiple documents )