MSUCOM ALUMNI QUESTIONNAIRE
Please help us keep in touch with you.  The information requested on this form will ensure that the college’s alumni files are up-to-date and accurate.  We never share this information outside the MSUCOM  and never sell it to commercial organizations.  Thank you for your help.
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About You:
Name:
Name at graduation (if different):
COM Class of:
Home Address:
City/State/Zip:
Phone:
Fax:
Email
About Your Practice:
Specialty:
Business Name:
Business Address:
City/State/Zip:
Phone:
Fax:
Email:
Preferred Mailing Address:
Medically Underserved Areas/Populations are areas or populations designated by HRSA as having too few primary care providers, high infant mortality, high poverty and/or high elderly populations.  Do you currently practice at least 50% of your time in a medically underserved community (MUC)?   Please indicate the type of MUCs below.  This information will be used in HRSA grant applications submitted by MSUCOM faculty.
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How would you best describe your practice? *
Do you have any news that you would like us to share?  This may include promotions, awards, job changes, etc.
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