高雄醫學大學教學發展與資源中心

申請人姓名 Name of applicant*

申請人職號 ID number of applicant*

聯絡電話 Contact number (mobile phone)*

Email*

學院 Academy*

醫學院 College of Medicine*

口腔醫學院 College of Dental Medicine*

藥學院 College of Pharmacy*

護理學院 College of Nursing*

健康科學院 College of Health Sciences*

生命科學院 College of Life Science*

人文社會科學院 College of Humanities and Social Science*

通識教育中心 Center for General Education*

申請教師姓名 (同申請人，則免填) Name of the applicant teacher (if same as the applicant, it is not required)

申請教師職號（同申請人，則免填）ID number of the applicant teacher (if same as the applicant, it is not required)

申請原因、用途 Application reason and purpose*

教師升等佐證資料（僅需教學型社群） Supporting materials for teachers' promotion

系所及相關評鑑使用 Department and related evaluation use

其它，請說明 other reasons：

欲證明之學期 Semester*

欲證明之社群屬性 Category of community

教學型 Teaching type

研究型 Researching type

自我成長型 Self-development type

單位主管 Supervisor Name*

單位主管Email Supervisor Email

高雄醫學大學為協助提供教師參與教學型教師專業成長社群證明之目的，須蒐集您的姓名、職號、電話、及其他證明文件等個人資料（辨識類：C001 辨識個人者），作為申請證明及台灣地區內進行聯繫，個人資料將保存6 個月（需依實際狀況調整）。如欲行使上述個人資料保護法第三條規定之當事人權利，請洽本校教務處教學發展與資源中心。本人已詳細閱讀上列告知事項且完全明瞭其內容。 For the purpose of assisting teachers to recruit TA or ATA, Kaohsiung Medical University must collect personal information such as your name, phone number, job number (identification category: C001 individual identification), as proof of participation in activities and contact within Taiwan. Personal information will be used Save for 1 month (will be adjusted according to the actual situation). When our school collects your personal information, if some fields are not filled in, it may affect your follow-up procedures such as activity contact and certification application. *

同意 I have fully understood the above notices and agree to your organization's collection, processing and use of my personal data.

依據本校專任教師新聘及升等計分標準第六條第一款第三項：負責規劃籌組教學型社群或參與，本處將提供參與教學型社群之證明。如有緊急或特殊需求，請加註說明。

中心業務

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依據本校專任教師新聘及升等計分標準第六條第一款第三項：負責規劃籌組教學型社群或參與，本處將提供參與教學型社群之證明。如有緊急或特殊需求，請加註說明。

中心業務

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