Department of PA Medicine Guest Lecturer Application

Name *

First

Middle

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Last 4 digits of SSN: *

Email: *

Mobile Phone Number: *

Assigned to teach:

Lecture topic/name of lecture:

Provide Qualification *

If other, please explain your qualification to teach your assigned lecture.

Attach: qualification topic/name

Medical Specialty:

Years in specialty:

Can you provide proof of eligibility to work in the U.S.? *

Have you pled guilty or been convicted of a felony within the last ten years? *

Attach: resume/CV, and professional license/diploma/specialty certificate *

Click or drag files to this area to upload. You can upload up to 5 files.

900 North Benton Avenue
Springfield, MO 65802