UNIFORMED SERVICES UNIVERSITYof the Health Sciences

1.Name (Caps)Last, First and Middle . 2. Military 3. Civilian 4. HJF1 Billeted

Non-Billeted Billeted Non-Billeted

Yes No

5. Faculty Action Requested . . . .

Appointment Tenure Tenure-Track Non-Tenure *Requested Title: Promotion Tenure Tenure-Track Non-Tenure Currently Tenured Yes NoReinstated Tenure Tenure-Track Non-Tenure Adjunct/Prefixed Yes No

Change in Track Tenure Tenure-Track Non-Tenure Track: 6. Department 7. Primary 8. Secondary 9. Current Title, Rank, Corp, Service

10. Education – Degrees, School, YearQUALIFICATIONS

*Note: See USU Instruction 1100 for information on USU Faculty appointments, promotion, or tenure.11. Current Address

12. Current Phone and Email Address .Phone Email Address

13. Requested by (Primary) Requested by (Secondary)

Signature and Date Signature and Date

Department Department

Chair/Head Chair/Head

1 (Attach additional forms if there are additional duties)

14. Approval (Signature & Date) 1 1 1CAPT Approved Disapproved Deferred President/BOR Approved Disapproved Deferred

USUHS Form 107 (REV. 2/15)

UNIFORMED SERVICES UNIVERSITY OF THE HEALTH SCIENCESREQUEST FOR CIVILIAN OR MILITARY FACULTY ACTION