Want to become an Alumni Ambassador? Please complete
the information below. An email address is required.
All information you send will be encrypted before it travels over the
Thank you for your interest in the Alumni Ambassador Program.
You will receive further information about the Alumni Ambassador Program from Alumni Relations. If you have questions regarding the program, please send an email to firstname.lastname@example.org or
Please review your information carefully and verify that all is correct.
You may also print this
form and mail it to Alumni Relations. The contact information appears below:
A.T. Still University
800 West Jefferson Street
Kirksville, MO 63501
web site is secured using a Thawte Digital Certificate and SSL
encryption technology to insure the privacy of all personal information
you send to us including your name, address and credit card numbers.