EmailMe Form - BSP Alumni Contact

Full Name *

Mailing Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Phone *

### - ### - ####

Current Email Address *

What is your preferred method of contact?

Phone

Email

Postal Mail

Are you currently attending/have you attended Graduate School (MA, MS, PhD, MSN, etc.)? *

Yes

No

If yes, which Graduate School Program are you attending?

If yes, when did/will you graduate?

Are you currently attending/have you attended Medical School? *

Yes

No

If yes, which Medical School are you attending?

If yes, when did/will you graduate?

Current Occupation/Career Field

Are you interested in being involved in the BSP's Alumni Chapter?

Yes

No

What other type(s) of involvement interest(s) you?

Mentorship program for current students

Serve on BSP Alumni Committee

Guest Lecturer (e.g. events, student activities)

Other

If you checked other, please explain below:

All data attained from this form will not be shared outside of BSP. This is for BSP use only.

I understand that clicking SUBMIT constitutes my electronic signature and, in doing so, certify that the information contained above is true and complete. I authorize the verification of any or all information listed above.

For help with the electronic application form please email biology_scholars@berkeley.edu.