Alumni Card Application Form - Queen Mary University of London

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Queen Mary Alumni Network
Alumni Card Application Form
Alumni Relations and Fundraising Office
Room CB100, First Floor, Queens’ Building,
Queen Mary, University of London, Mile End Road, London E1 4NS, UK
Tel: +44(0)20 7882 7790; email: [email protected]
Title
First name(s)
Surname
Personal email address (ie. NOT with the suffix; qmul.ac.uk)
College username (ie. leO761)
Date of birth
Student ID no.
Graduation/qualification year
College
Address (including postcode)
Mobile
Insert digital
passport-style photo
here (only if emailing
document)
Telephone
Department of study
Subject studied
Please let us know what you are going on to do:
□
Employment
□
Currently looking for employment
□
Further study
□
Other (please state ________________________________________)
If you are working, please let us know your:
Job title ________________________________________________________________
Organisation ____________________________________________________________
Please tick as appropriate:
□ I would like to have my college email address forwarded to my personal address as above.
(This option is only available to students who possess the personal email format, introduced in 2010. e.g. [email protected])
□ I would like to apply for an alumni.qmul.net email address. I would like to personalise my Alumni Email
Address as [email protected] (this option is only for alumni students who did not have an email
address with a personal name introduced in 2010 e.g. [email protected])
□ I wish to receive the QM Alumni e-Newsletter (a digest of College news sent to your inbox on a
monthly basis).
□ I wish to be included in the Web email Directory (a password-protected site where you can share
your email address with alumni from across the years).
□ I understand that the above details will be kept on computer in accordance with the Data
Protection Act currently in force.
□ I consent to receiving mailings in connection with the Queen Mary Alumni Network.
Signature
Date
For Office use only:
Alumni Reference no:
Method of Payment: Online, Cash, Cheque no.___________, Postal order, Credit/Debit card
Date processed:
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