|
Please fill in the form as completely as possible.
* indicates required field.
NOTE: Please be sure to specify your opt-in/opt-out choices using the yes/no buttons below. This information is also being used for your online directory entry.
|
Name
|
|
Last name:
|
*
|
|
First name:
|
*
|
|
Initial:
|
*
|
|
Prefix:
|
|
Home Address
|
|
Address 1:
|
*
|
|
Address 2:
|
|
|
Address 3:
|
|
|
City:
|
*
|
|
State (Province,
Region):
|
|
|
ZIP (Postcode):
|
|
|
Country:
|
|
|
|
Other Contact Information |
|
Home phone:
|
Format: (206) 555-1111
|
|
Preferred e-mail:
|
|
|
Secondary e-mail:
|
|
|
Website:
|
|
|
|
UW Degree and Specialty Information |
|
† Preferred UW
class year:
|
|
|
First UW degree/residency/fellowship
|
|
Type:
|
|
|
UW graduation or completion year:
|
|
|
UW major or specialty:
|
|
|
|
|
Second UW degree/residency/fellowship
|
|
Type:
|
|
|
UW graduation or completion year:
|
|
|
UW major or specialty:
|
|
|
|
|
Third UW degree/residency/fellowship
|
|
Type:
|
|
|
UW graduation or completion year:
|
|
|
UW major or specialty:
|
|
|
|
|
Fourth UW degree/residency/fellowship
|
|
Type:
|
|
|
UW graduation or completion year:
|
|
|
UW major or specialty:
|
|
|
Other/Secondary Specialty:
|
|
|
|
|
†
|
If you graduated with a later class, or in some cases, early — in December of the year prior, but have an affinity with your "entering" year class — you may identify a "preferred" class year for the purposes of class mailings and reunion information.
|
|
Business Information
|
|
Employer name:
|
|
|
Job title:
|
(ie. Medical Director, V.P., etc)
|
|
Address 1:
|
|
|
Address 2:
|
|
|
Address 3:
|
|
|
City:
|
|
|
State:
|
|
|
ZIP (Postcode):
|
|
|
Country:
|
|
|
Work phone:
|
Format: (206)555-1111
|
|
FAX:
|
Format: (206)555-1111
|
|
|
Classnote
|
|
(Update your classmates on what you've been doing, career highlights, and family news).
|
|
|
|
|
|
|
