Alumni contact information and update form
Thank you for helping us stay connected! If you have any questions while filling out this form, please feel free to contact the Alumni Affairs Office at (909) 469-ALUM or via e-mail at
I wish to Change my address   Update my personal information
First Name:   Middle Name/Initial:
Last Name:  
Class Year:  Degree:
Specialty (if applicable):  
Board Certified:
If this is a name change, what name appeared on your transcripts?:  
I prefer to receive mailings at my: home   business
City:   State:   Zip:
Home Phone:  
Business Name:  
City:   State:   Zip:
Business Phone:  
I wish to receive alumni news and university updates by e-mail.
I give permission to the Western University Alumni Affairs Office to list only my name, class year, and e-mail address in the upcoming online directory of Western University' Alumni Association Web site.
Spouse/Significant other (if applicable):
Children (names & ages):
Let us know about your recent career accomplishments!:
Additional education or training received after Western University:
Professional organizations/offices held:
Other professional/ personal information you wish to share:
Favorite Memory or Personal Story of your time on campus!: