Alumni Board Membership Form

Thank you for serving on your school's Alumni Chapter Board of Directors. Please complete the following form and submit online. If you prefer a paper copy or having any questions, email alumni@umc.edu or call (601) 984-1115.

* = Required Fields

Name of Nominator*
Name of Board Nominee*
School*	School of Dentistry School of Graduate Studies School of Health Related Professions School of Medicine School of Nursing School of Population Health
Nominee Class Year*
Nominee Employer/Practice Name*
Nominee Cell Number*	() -
Nominee Email Address*
Please list contributions/accomplishments of nominee in the areas of clinical service, research, education, and/or administrative leadership. Please be specific.*
Resume/CV	*.txt,*.doc,*.docx,*.xls,*.xlsx,*.pdf, *.gif,*.jpg,*.jpeg,*.bmp,*.png,*.tif,*.tiff