A.T. Still University

Alumni Ambassador Program

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 Internet.

Your Information
*First Name:
*Middle Initial:
*Last Name:
*Please indicate all the ATSU college/schools and programs from which you graduated:
ATSU College/School Program Graduation Year
*Email Address:
*Type of Practice
(if applicable):
Work Address
Work Phone Number:
- -
Name of Business:
Work Address:
Home Address
Home Phone Number:
- -
Home Address:

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 alumni@atsu.edu or call 660.626.2307.

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:

Alumni Relations
A.T. Still University

800 West Jefferson Street
Kirksville, MO 63501
Email: alumni@atsu.edu
Phone: 660.626.2307
Fax: 660.626.2370

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