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MSSP Alumni - Contact / Information Sheet

General Information

First Name: *required	Last Name: *required
Maiden Name (if applicable):

Mailing Address

Street address: *required

City: *required

State: *required Zip Code: *required

Home Phone:

Cell Phone:

Work Phone:

Current Employer:

Position:

How long in this position?

E-Mail

We have an MSSP Alumni e-mail list serve. We use this e-mail to send out updates, event information, job opportunities, etc. Please check the box next to any e-mail you would like us to include on that list serve.
Personal Email address: Yes, include on list serve

Work Email address: Yes, include on list serve

WOU Information

Year(s) you attended WOU: from to	Graduation Term/Year:
Major(s):	Minor(s):

MSSP Information: Please check all that you participated in:

MSU Member

MSU Exec Member

Multicultural Recruiter (MCR)

Diversity Scholar (Recipient of UMAS/Underrepresented Minorities Achievement Scholarship, Peggy Hyatt Scholarship, David S. Brody Memorial Scholarship, OMSLI Scholarship, Diversity Achievement Scholarship, Diversity Commitment Scholarship)

On-Track Participant

Other:

Personal Information:

Married? Yes No

Children? Yes No

Spouse's/Partner's Name:

Child(ren)'s Name(s):

Contact

Multicultural Student Services 503-838-8737 | or e-mail: mssp@wou.edu

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