PERSONAL INFORMATION

Last name *:

First *:

Father’s Name *:

Birth date *: MM/DD/YY

Email 1 *:

Email 2:

Family INFORMATION    Private               Public

Marital status :

Spouse Name:

Is your spouse an HCU Alumnus?

Single  Mar  Div  Sep  Wid

Yes                 No

Children:

Name

Gender

Is s/he an HCU Graduate?

Contact Information  Private               Public

Primary Address *:

City *:

State/Province:

Country *:

Building *:

Floor *:

Postal Address *:

Mobile phone no *:

Home phone no:

Secondary Address:

City:

State/Province:

Country:

Building:

Floor

Postal Address::

Phone No.

oCCUPATIONAL INFORMATION        Private               Public

1. Employment:

Position/Title *:

Company *:

Branch (if applicable):

Division/Department:

Country *:

Work phone no *:

Fax no:

2. Self-Employment:

Form of Self-Employment *:

Company/Enterprise *:

Country *:

Work phone no *:

Fax no:

HCU ACADEMIC INFORMATION

HCU ID No *:

Graduation Year/ Semester *:

College/ Department *:

Major *:

Minor (if applicable):

Degree (s) *:

General ACADEMIC INFORMATION Private               Public

Are you a member of a professional:

a- Local Organization/Institute?

Yes

If yes, please specify:

No

b- International Organization/Institute?

Yes

If yes, please specify:

No

Other Membership(s)?             Please specify:

Enrollment in Universities other than HCU? *

Yes           No                           

                                                If Yes:   Currently enrolled

                                                            Already Graduated

                                                            Planning to enroll

University *:

City:

State/Province:

Country:

Faculty *:

Major(s) *:

Degree *:

Year of enrollment and graduation:

Other Information      Private               Public

Awards, Honors, Promotions received:

Publications (citations):

Leadership Roles:

Additional Comments/ Suggestions: