First Name:
Last Name:
Maiden Name:

Race/Ethnicity(please check all that apply):	Black or African American American Indian or Alaskan Asian/Pacific Islander Hispanic Other(please specify)

MD or MSTP Year of Graduation:		Degree:
Undergraduate Year of Graduation:
Undergraduate Institution:
Degree and Major:
Other Degrees (if applicable):

Current SNMA members are very interested in contacting minority alumni. May we include the information detailed on this form in a confidential online database that will be accessible to WUSM medical students an eventually residents, fellows and other WUSM alumni?

Please check one: Yes No

Please check the following box if you would like to receive an "SNMA" news" update each semester.

Yes

For the following, please supply all that you would like us to use:

Check if contact information is not good:	Yes
Comments:

Contact information - Home
Street Address:
City:
State:
Zip Code:
Phone Number:
Email Address:

Contact information - Business
Current Title/Position:
Street Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
Email Address:

How would you like to be contacted?(Please select one):

Email-Home Email-Business Mail-Home Mail-Business

Which best describes your CURRENT professional situation:

residency training, primarily clinical responsibilities residency training, primarily research responsibilities clinical fellowship research fellowship practicing physician, private practice practicing physician, hospital/medical group; academic setting practicing physician, hospital/medical group; nonacademic setting practicing physician, governmental non-military employee practicing physician, military employee working in a medical field but not practicing medicine (please specify) working in a non-medical field (please specify) not presently working Residency training, primarily clinical responsibilities Residency training, primarily research responsibilities Clinical Fellowship Research Fellowship Practicing physician, private practice Practicing physician, hospital/medical group, academic setting Practicing physician, hospital/medical group, nonacademic setting Practicing physician, governmental non-military employee Practicing physician, military employee Working in a medical field but not practicing medicine_specify below Working in a non-medical field_specify below Not presently working

POST GRADUATE CAREER PATH

Residency-Preliminary (if applicable):		Year(s):
Hospital Address:
Hospital City:
Hospital State:
Hospital Zip:

Residency - Specialty (please check all that apply)
	Anesthesiology Dermatology Diagnostic Radiology Emergency Medicine Family Practice General Surgery Internal Medicine Neurology Neurological Surgery Obstetrics and Gynecology Ophthalmology	Orthopaedic Surgery Otolaryngology Pathology Pediatrics Physical Medicine and Rehabilitation Plastic Surgery Psychiatry Radiation Oncology Research Urology

Residency Hospital:		Year(s)
Residency City:
Residency State:
Residency Hospital (if more than one):		Year(s)
Residency City:
Residency State:
Fellowship (if applicable):		Year(s)
Fellowship Hospital:
Fellowship City:
Fellowship State:

RESEARCH AND OTHER MEDICAL INTERESTS

COMMUNITY SERVICE, HOBBIES AND OTHER ACTIVITIES

ADDITIONAL COMMENTS