Members Only Area*

CIA Student/Alumni Network
Information Sheet

Submit the following information about yourself to be included in the Certificate in Aging Student/Alumni Network Database. Note: If this is an update to an existing record, please fill out the first 3 questions and then just whichever fields need updating.

Basic Info

1. Your PID :

2. Are you an: alumnus current student

3. First Name: Last Name:

Background

4. Discipline: (Ctrl+click to choose more than one)

5. Highest degree:
Date Degree Received: (yyyy)
College/University Name:

6. CIA completion date (anticipated or actual) (yyyy)

7. Employer Name

Job Title

Contact Info

8. Please give us your contact info

	This information will be kept confidential unless you check boxes to the right	Check here if you are willing to have other CIA students contact you
Email:
Phone:
Mail:

Your Interests

9. Describe your area of interest in aging:

10. Indicate which of the following CIA activities you would be interested in or willing to do:

Mentoring

Give a presentation in your area of expertise

Collaborate on a manuscript

Collaborate on a research project

Participate in CIA events/projects

Other:

Comments

11. Please comment on what the CIA can do for you: