First Name :
Last Name:
Middle Name:
Telephone (w/area code):
Birth Date (mm/dd):
E-mail Address:
Permanent Street Address:
City:
State:
Zip Code:
Do we have permission to contact you?		Yes No
If yes, how would you prefer that we communicate with you?		E-Mail Phone Postal Mail No preference

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Educational Background:

Major(s) at Miami :
Minor(s) at Miami :
Year of Miami Graduation :
Major clubs or organizations that you were involved in at Miami::
Did you attend graduate or professional school?		Yes No
If yes, where did you attend and what degree did you earn?

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Professional Information:

What is your field or profession?
Company Name :
Your title or position at that company:
Professional involvements, awards, or accomplishments:

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Receive Information or Get Involved:

We are currently in the process of developing various ways for H&S alumni to get involved or receive information. Listed below are projects that are currently in development. PLEASE CHECK ALL THAT APPLY.

I would be interested in:
		Receiving a quarterly newsletter for Honors & Scholars alumni and friends.
		Participating in efforts to recruit new students to the Honors & Scholars Program
		Setting up an internship for a current student at your workplace.
		Acting as a mentor to a current student interested in your field or profession.
		Visiting campus and participate in a program with current students.