School of Medicine

Class of 1967 Bio Information

 

 

Class of 1967 Bio Information

ATTENTION: Class of 1967.
Please complete the Medical Reunion Class Survey by JULY 30. We are composing a Commemorative Book honoring our 50 year graduates which will be available at the Medical Reunion on August 10-12.

* = Required Fields

Name* 
Spouse
Address (Home)* 
City/State/Zip Code*  
Address (Business)
City/State/Zip
Email
Fax
Phone (home)() -
Phone (business)() - x
Phone (cell)() -
Practice Specialty
Retired?
If yes, year retired
Residency School(s)
Res. Graduation Year
Professional/personal accomplishments since medical school
Best memory of your time in the School of Medicine
Classmate whom you have remained in close contact since graduation?
Favorite faculty and why
Do you have children? Names, ages, careers, hobbies
Special interests, activities, travel
Please submit a recent photo of yourself
*.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff