ADDRESS UPDATE FORM

Does the Alumni Association have your current address information?

Please take a moment to update us so that you will continue to receive the Alumni JOURNAL and other Alumni Association mailings. Unless you request otherwise, the following information will appear in the Alumni DIRECTORY.

Fill in, print, and FAX this page to (909) 558-4638.

Thank you!

Today's Date (mm/dd/yy):

Name:

Year of Graduation:

Spouse's First & Maiden/Last Name:

Home Address:

Home Phone (include area code):

Office Address:

Office Phone (include area code):

Fax (include area code):

E-mail:

HAM Call Sign:

Practice Specialties:

Board Certification(s):

Society Memberships & Other Earned Degrees:

Do you wish to have this information listed in the DIRECTORY? YES   NO

Do you wish to have your residence address listed in the DIRECTORY? YES   NO