MSUCOM ALUMNI QUESTIONNAIRE
Please help us keep in touch with you. The information requested on this form will ensure that the college’s alumni files are up-to-date and accurate. We never share this information outside the MSUCOM and never sell it to commercial organizations. Thank you for your help.
About You:
Name:
Your answer
Name at graduation (if different):
Your answer
COM Class of:
Your answer
Home Address:
Your answer
City/State/Zip:
Your answer
Phone:
Your answer
Fax:
Your answer
Email
Your answer
About Your Practice:
Specialty:
Your answer
Business Name:
Your answer
Business Address:
Your answer
City/State/Zip:
Your answer
Phone:
Your answer
Fax:
Your answer
Email:
Your answer
Preferred Mailing Address:
Medically Underserved Areas/Populations are areas or populations designated by HRSA as having too few primary care providers, high infant mortality, high poverty and/or high elderly populations. Do you currently practice at least 50% of your time in a medically underserved community (MUC)? Please indicate the type of MUCs below. This information will be used in HRSA grant applications submitted by MSUCOM faculty.
How would you best describe your practice?
Your answer
Do you have any news that you would like us to share? This may include promotions, awards, job changes, etc.
Your answer
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