Associate Alumni Expression of Interest - for former University of Alberta medical or dental residents
In June 2012, the University of Alberta's Board of Governors and President's Executive Committee confirmed the decision to recognize learners who completed their residency at the University of Alberta as 'Associate Alumni.'

'Associate Alumni' status provides access to all of the opportunities and benefits available to alumni of the University of Alberta.

Those who started their residency program in 2013 and onwards are automatically added to the University of Alberta's alumni database. For those who started prior to 2013, please complete the following form to consent to having an alumni record created in your name and provide us with your current contact information.
Sign in to Google to save your progress. Learn more
Privacy
The personal information requested on this form is collected under the authority of Section 33(c) of the Alberta Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act. It will be used for the purpose of verifying completion of the certificate program, and for alumni engagement and philanthropic activities. Questions concerning the collection, use or disclosure of this information should be directed to the FOIPP Liaison Officer, Office of Advancement, University of Alberta, 3-501 Enterprise Square, 10230 Jasper Ave, Edmonton, AB, T5J 4P6 (780) 492 7400.

See our privacy policy here: https://www.ualberta.ca/alumni/privacy-policy.html

The University of Alberta does not sell any personal information that it collects.
As a past medical or dental resident at the University of Alberta’s Faculty of Medicine & Dentistry, I would like to become an Associate Alumnus of the University of Alberta Alumni Association. *
Prefix
Clear selection
First Name *
Middle Name
Last Name *
Former Name
Preferred email address *
Preferred phone number *
Student ID (if known)
Residency Information
Residency Program Completion Year *
Residency Program *
Residency Specialty *
Please list any other degrees with graduation year you have from the University of Alberta.
Home address
Address *
City *
Province / State *
Postal Code / Zip *
Country *
Business Address (optional)
Company / Organization
Position
Address
City
Province / State
Postal Code / Zip
Country
Business phone number
Business email
Address preferences
Preferred Mailing Address *
Spouse / Partner Information (Optional)
Spouse / Partner's Full Name
Spouse / Partner's Former Name
Is your spouse also an alumnus/alumna of the University of Alberta?
Clear selection
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of University of Alberta. Report Abuse
Google Forms