American University of the Caribbean

AUC Alumni Update Form
Help us keep our records up-to-date, so we can keep you-up-to date! To be sure our records are accurate and current, please take a moment to tell us about yourself and where you are now. Required data fields are marked with an asterisk (*), and must be completed before you submit the form.
Personal Information
	Name: First Middle Last
	Name while attending AUC (if different):
	First Middle Last
	Year of Graduation: Date of Birth (mm/dd/yyyy): Marital Status:* Single Married Divorced Widowed
Contact Information
	*E-mail Address:
	Alternate E-mail Address:
	*Home Address:	Street

		*City	*State	*Zip
	Home Phone Number:
	Mobile Phone Number:
	Job Title:
	Business Name:
	Work Address:	Street

		City	State	Zip
	Work Phone Number:
	Fax Number:
Residency Information
	Did you obtain a residency? Yes No
	First Residency:	Specialty
		Location
		City	State
		Start Date (mm/dd/yyyy)
		End Date (mm/dd/yyyy)
		Match Pre-Match Scramble Other N/A
		Was this residency one of your top 3 choices?
	Second Residency:	Specialty
		Location
		City	State
		Start Date (mm/dd/yyyy)
		End Date (mm/dd/yyyy)
		Match Pre-Match Scramble Other N/A
		Was this residency one of your top 3 choices?
	Third Residency:	Specialty
		Location
		City	State
		Start Date (mm/dd/yyyy)
		End Date (mm/dd/yyyy)
		Match Pre-Match Scramble Other N/A
		Was this residency one of your top 3 choices?
Fellowship Information
	Fellowship:	Specialty
		Location
		City	State
		Start Date (mm/dd/yyyy)
		End Date (mm/dd/yyyy)
Additional Information
	1. Are you a member of the American Medical Association? Yes No
	2. Are you a member of the AUC Alumni Assocation? Yes No If no, please join at www.aucalumni.net.
	3. Are you Board Certified? Yes No If yes, please specify:
	4. What state(s) are you licensed in?
	5. Would you be willing to contact newly admitted and/or prospective students? Yes No