Networking Initiative Volunteer Form 2024 Volunteer Details The following information will be used by the Admissions Office to pair you with an incoming student, and to contact you, when necessary. Note: All questions are required. If a question does not apply to you, please enter N/A in the field. First Name: Last Name: Name of Medical School from which you graduated: Graduation Year: Affiliation (Select all that apply): Einstein Alumni Association National Hispanic Medical Association Westchester and Bronx Society of Black Physicians Are you an Einstein Alumnus? Yes No Academic Title, if any: Department: Subspecialty: I am most involved in: (Please check all that apply) Clinical practiceA career with research includedGlobal and/or public healthBiotech and pharmaceutical industryOther non-traditional career opportunities Please Describe: Hospital Affiliations (Names and Locations): Office Mailing Address Address: City: State: Select State N/A Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip: Contact Information Email: Office Phone Number: Cell Phone: The following information will be given to the incoming student to contact you. Please indicate your preferred contact information. For instance, would you prefer to be contacted by cell phone, by email, or by office telephone? I prefer contact via cell phone I prefer contact at my office I prefer contact via email (If you select to receive an email, we will ask your student to write on the Subject Line: ADMISSIONS - ALBERT EINSTEIN COLLEGE OF MEDICINE NETWORKING INITIATIVE)
