EPIIC ALUMNI UPDATE FORM

Please take a moment and update your contact information.

1. Alumni Information

First Name*: Last Name*:

EPIIC Colloquium Year*: 1985-1986 1986-1987 1987-1988 1988-1989 1989-1990 1990-1991 1991-1992 1992-1993 1993-1994 1994-1995 1995-1996 1996-1997 1997-1998 1998-1999 1999-2000 2000-2001 2001-2002 2002-2003 2003-2004 2004-2005 2005-2006
(Multiple selections allowed)

Undergraduate Major: Graduated/Expected Graduation: 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

2. Home Address/Contact Information

Street Address 1:

Street Address 2:

City:

State/Province/Region:

Zip/Mail Code:

Country:

Personal Email Address*:
Do we have your permission to post this address on the EPIIC website? Yes No

Telephone Number: (123) 456-7890

Fax Number:

Mobile Telephone Number:

3. Work Address/Contact Information

Street Address 1:

Street Address 2:

City:

State/Province/Region:

Zip/Mail Code:

Country:

Work Email Address :
Do we have your permission to post this address on the website? Yes No

Telephone Number: (123) 456-7890

Fax Number:

4. Update Information:

Currently I am (Check all that apply): Working Studying Conducting Independent Research

A) Current Employment (if applicable)

Company/Institution: Status: Private Company Government NGO

Current Job Title: Years at current institution:

Company Website URL:

 

B) Current Academic Studies (if applicable):

Current Academic Institution:

Degree Pursued: Degree Conferment Expected:

 

C) Independent Research (if applicable):

Research Topic: Research Location:

5. Detailed Description:

Please provide a detailed description of your current job, academic studies or research*:

Please describe what you've done between the end of the EPIIC program and your current work, study or research. Also update us with any extracurricular activities (volunteer projects, extended travel, etc):

6. Photograph for Profile

Photograph For EPIIC Profile

Browse your computer for the photo you would like to use. After you select it, the file will be uploaded when you submit the completed form at the bottom of the page.

7. Additional Comments:

Please let us know if you have any special concerns, particularly regarding your online profile. You can write your own profile below, or just leave us comments about it:

Thanks again!

Email Ben Mann at ben.mann@tufts.edu if you encounter difficulties using this form.