Class of 2010 Questionnaire

Class of 2010 Online Directory Questionnaire

Please fill out the following personal information in the boxes below. When you are finished, click the “submit” button on the bottom of the page.Name:

Specialty:

Home Address:
(please include apt.# if applicable)

Home Telephone:

Email:

Hopital/office address where you will intern:
(please type the full mailing address including department)

Hospital/office telephone:

I prefer to receive mail:
Home
Hospital/Office

Please complete this form no later than June 30, 2010. If we do not hear from you, the information provided in the Graduation Program will be included in the online directory. If you do not wish to have your information included in the online directory, please inform the Alumni Association in writing via mail, fax or email.

The following information is not for Directory publication:I prefer to attend Reunions of the Class of (if other than 2009).

Spouse’s name:

COMMENTS:

For more information contact:
BUSM Alumni Association
72 E. Concord Street, L-120
Boston, MA 02118
617/638-5150
e-mail: alumbusm@bu.edu

Boston University Medical Campus
Alumni Association