NEA

Non-Employee Associate Form (College of Medicine Only)

Instructions: After you fill this application the email will be send to Campus or Department for the appropriate approvals.

* I, a Non-Employee Associate of Drexel University College of Medicine (DUCOM), require account access to DUCOM services ("Account Privileges") because I am a(n)

Affiliated Faculty

Affiliated Resident/Fellow

Affiliated Staff

Non-Drexel Student

Other, please describe

Department

Division/Speciality

* Are you requesting NEA status to support your activities in a Drexel research project or projects?

Yes

Demographic Information

Prefix

Suffix

Preferred First Name

* Legal First Name

Middle Initial

* Last Name

* SSN (shown only to HR)

Personal Pronouns

* Date of Birth

* Legal Sex
Female Male Prefer Not to Answer

* Citizenship

The following questions are optional but assist in reports that we are required to provide to various agencies

Gender Identity

Ethnicity

Race (Multiple choices can be selected using Ctrl)

Contact and Work Information

* Primary professional email address

Personal Email (this will not be used for formal communications)

Current Employers (list all and include if it is a Full Time or Part Time Position

Primary Work Address

* Institution

* Address

* City

* State

* Zip Code

* Phone

Home Address

* Address

* City

* State

* Zip Code

* Home/Cell Phone

* Are you legally eligible to work in the US for the duration of your assignment?

Yes

* Have you been associated in anyway (ie. applicant, student, paid engagement, prior NEA) with Drexel University or an affiliate such as Drexel University Online, ANS, etc.

Yes

I understand that I am not an employee of Drexel University and therefore I am not entitled to compensation or benefits of any kind, including, but not limited to, workers' compensation, unemployment compensation or health insurance. I understand that in receiving Account Privileges, I agree to abide by all Drexel University policies and procedures relating to the Services as may be in effect from time to time. Such policies and procedures can be found at https://drexel.edu/hr/resources/policies/ and www.library.drexel.edu/about/librarypolicies.html. I further agree that any violations of Drexel University's policies or procedures shall result in the immediate revocation of my Account Privileges. I understand that my Account Privileges shall be reviewed on an annual basis.

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By submitting this form you are acknowledging that all information is correct

* Either Campus or Department is required

Campus