Alumni Update & Speaker Interest Form
Name
*
Title
Current Address (personal)
State
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Zip Code
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Country
Phone Number
E-Mail Address
*
Organization
AMSA Membership Number
School
Degree
Year Graduated
What are you doing now?
How has AMSA affected your career?
What is your favorite memory about AMSA?
Are you interested in speaking to an AMSA Chapter, in an AMSA Scholars or Leadership Program, or at an AMSA Convention?
Yes
No
Please list topics/issues you could speak on here
Would you be interested in being a subject of an article in The New Physician, &/or interviewed for our upcoming AMSA History Collection Project, etc?
Yes
No
Would you be interested in helping to organize an alumni event?
Yes
No
May we contact you about opportunities to engage with AMSA?
Yes
No
May we post your contact information in the alumni database?
Yes
No
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