Alumni Questionnaire

ALUMNI QUESTIONNAIRE
* = Required Field
TELL US ABOUT YOURSELF
Title
First Name*
Middle Name
Last Name*
Previous Name (if applicable)
Spouse's or Partner's Name

UC BERKELEY DEGREE(S)
	Degree One	Degree Two
Major*
Degree*
Year*
Semester
Research Director

DEGREES FROM OTHER INSTITUTIONS
	Degree One	Degree Two
Institution
Major
Degree
Year


CONTACT INFORMATION
Email*
Home Address	New? Yes No
Street
City
State
Zip/Postal
Country
Phone

Work/School Address	New? Yes No
Position
Start Date
Job Function
Job Type
Name of Organization
Division
Street
City
State
Zip
Country
Phone
Send Mail To	Home Work

CONTACT PERSON Name and address of someone who will always know how to contact you


CLASS NOTES Tell us your news! Recent promotions, family additions, exciting trips, etc...


COLLEGE OF CHEMISTRY ALUMNI ASSOCIATION/ACTIVITIES
I want to join the Alumni Association (it's free!)	Yes No
I want to help by:
Participating in future planning for the association	Yes No
Planning events in my area (with the assistance of the college)	Yes No
I am interested in participating in the following:
Lectures or Symposia	Yes No
Social Events	Yes No
Career Networking	Yes No
Grad student recruitment	Yes No

I grant permission for the publication of my news, but NOT my address information, in the "Class Notes" section of the College of Chemistry News Journal
Yes, I grant such permission No, I do not grant such permission
Please enter text in image:

Last Modified:
03/07/2013 02:10:13 PM