Alumni and Faculty Directory Form

Department of Ophthalmology and Visual Sciences
Alumni and Faculty Directory Form

It is time again to update the University of Michigan Department of Ophthalmology and Visual Sciences Alumni and Faculty Directory. The Alumni and Faculty Directory will include all of the information that is highlighted in yellow, while the other information is for our records. If you would prefer that a highlighted data point such as a home address not be published in the directory, please indicate that in the Comments section of this form.

Full Name:
Your Birthdate:	Retired?: Yes No
Spouse's Name:
Children: Name with birthdate

Home Information
Home Address:
Home Phone:	Home Fax:
Email:

Education
Resident Graduation Year:	Fellow Graduation Year:
Medical School Attended:
Residency (if not at UM):
Fellowships (if not at UM):
Subspecialty:

Office Information
Office Address:
Office Phone:	Office Fax:

Seasonal Information
Seasonal Address:
Seasonal Phone:
Please specify dates you are at seasonal address:

Additional Comments: