A.T. Still University

Alumni Contact Information Form

Please fill out the form below.  The biographical information you provide will be used for internal ATSU use only.  This information is considered confidential.

The ATSU Alumni Directory is now available online in the Alumni Portal, which is name and password protected. To access it, you need an ATSU email address and password. Your preferred address, email, and phone number appear in the directory with your name, degree, ATSU school/college, and graduation year.

If you do not want your contact information to appear in the directory, please indicate it here:



Please complete the following (for internal ATSU use).
First Name:
Middle Name:
Last Name:
Prefix:
Suffix:
Birth Name:
(first, middle, and last)
SCHOOLS/PROGRAMS
  ATSU College/School Program Graduation Year
Please indicate all the ATSU college/schools and programs from which you graduated:
HOW MAY WE REACH YOU?
Home Address:
City:
State:
Zip:
Home Phone :
 - -
Home Fax:
- -
Home E-mail Address:
Personal WWW Address:
Name of Business:
Business Address:
 
City:
State:
Zip:
Business Phone: 
- -
Business Fax: 
- -
Business E-mail Address:
Business WWW Address: 
Cell Phone Number:
- -
ATSU Alumni Email Address:
Preferred mailing address:
Preferred email address:
What is the best way to communicate with you:
ALUMNI SURVEY  
Are you:
Fellowships/certifications,
if appropriate:
Type of Practice and/or Occupation:
Are you working:
Gender:
Date of Birth:
/ /
How do you describe yourself:
  If other, please explain:
Country of Citizenship:
Marital Status:





Spouse/Significant Other's First Name:
Spouse/Significant Other's Last Name:
Spouse/Significant Other's Birth Name:
Spouse/Significant Other's ATSU
Graduation Date, if applicable:
Spouse/Significant Other's Occupation and Employer:
Children/Stepchildren
 
Name:
Name:
Name:
Name:
Name:
Name:
Name:
Name:
Name of your undergraduate institution(s) with city/state and degree:
Are you currently serving in the military:
If yes, which branch:
Current rank:
Active duty:
Reserve:
National Guard:
   
If not currently serving, have you ever served:
 Yes No
If yes, in which branch did you serve:
Highest rank held:
Are you willing to serve as an Alumni Ambassador for prospective applicants and current students:
If yes, please note that we will release your preferred contact information to prospective applicants and current students.
Optional:  Update your alumni file by submitting the following:
  1.  Curriculum vitae
  2. Photo
Send electronic copies to alumni@atsu.edu.  Hard copies will not be returned.
ALUMNI NEWS

Keep ATSU and your classmates informed about you and your achievements! Alumni News submitted to this site will be considered for inclusion in ATSU publications. All submitted information is subject to review and approval by ATSU Alumni Relations before being released for posting.

Personal:
Professional:
Hobbies:
Vacation:
Alumni News submitted to this site will be considered for inclusion in ATSU publications.
I do not wish to include my Alumni News in ATSU publications.

Yes, please display my news on the ATSU Online Alumni News website.

Alumni Relations
A.T. Still University
800 West Jefferson Street
Kirksville, MO 63501
Phone (toll free):  866.626.2878, ask for ext. 2307
Phone (direct):  660.626.2307
Fax:  660.626.2970
Email:  alumni@atsu.edu
www.atsu.edu

This 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 telephone numbers.