Alumni Information Update

Your Name

*Indicates a required field.
First Name:*		Last Name:*
Maiden Name:

E-mail Address

Preferred e-mail address for Bastyr communications:

Alumni Web Directory Information

This public directory exists to help promote our graduates as health professionals. We recommend that you use your business contact information.

Business Name:

Street Address:

Address 2:

City: State:

Postal Code: Country:

Phone: Fax:

E-mail: Web Address:

Professional Focus:
15 words or less

May we publish the above Alumni Directory information to the public on the Bastyr Web site? Yes No

Business Contact Information

Same as Web Directory Information above (if so, no need to fill in section below)
Business Name:
Street Address:
Address 2:
City:		State:
Postal Code:		Country:
Phone:		Fax:
E-mail:		Web Address:

Home Contact Information

Address:
Address 2:
City:		State:
Postal Code:		Country:
Phone:		Fax:
E-mail:		Web Address:

Preferences

Preferred address to receive mail from Bastyr:*

Preferred year of graduation:*
If you have multiple degrees from Bastyr, please let us know which year of graduation you want us to use for reunion and anniversary notices. If you do not specify a preference, the year in which you received your first degree or certificate will be used.

Personal News

May we reprint your Personal News in Alumni Notes on the web? Yes No