Tulane University School of Medicine Administration

Medical students talking in the hospital

Personal Information
First Name:
Maiden Name:
Last Name:
Social Security Number:
Birthday (mm/dd/yyyy):
Graduating Class Year:
Birthplace:
e-mail:
Country of Legal Residence:
Gender:
Ethnic:
Marital:
Legal Residence State:
Mailbox:
Local Address
Street:
City:
State:
Zip Code:
Phone:
Cell Phone:
Beeper:
Permanent Address
Street:
City:
State:
Zip Code:
Phone:
Louisiana Driver's License Number:
Are you registered to vote in the state of Louisiana?:
NOTE: Please list your parent's or other relative's address and phone number
Billing Address
Name:
Street:
City:
State:
Zip Code:
Phone:
Relationship:
Please notify in case of emergency
Name:
Street:
City:
State:
Zip Code:
Phone - Work:
Phone - Home:
Relationship:
Father
Name:
Street:
City:
State:
Zip Code:
Phone:
Occupation:
Employer:
Living:
Mother
Name:
Street:
City:
State:
Zip Code:
Phone:
Occupation:
Employer:
Living:
Spouse/Other
First Name:
Maiden/Last Name:
Occupation:
Employer:
Hometown and State:
Children
Name:
Age:
Name:
Age:
Name:
Age:
Alumni Relations
If any member of your family is a graduate of the Tulane University School of Medicine, please provide the following information:
Name:
Relationship:
City of Residence:
State of Residence:
Type of Practice:
Living:
Year of Graduation:
RELEASE OF INFORMATION: Information such as that on the preceeding pages is available to members of the faculty and administration who have legitimate need for access to it. The Office of Student Affairs is often asked for address and telephone numbers of our students. It is department policy not to release such information but instead offer to have the student return the call. The Student Executive Committee publishes each year a student directory of addresses and phone numbers, and various other student groups request addresses and phone numbers of students. In order that we may follow your wishes in this matter, please answer the following questions by choosing "YES" or "NO" below: MAY WE RELEASE YOUR LOCAL ADDRESS AND/OR PHONE NUMBER TO TULANE STUDENTS COMPILING CLASS OR SCHOOL DIRECTIORIES? Address: YES NO Phone: YES NO STATEMENT OF FINANCIAL RESPONSIBILITY (REQUIRIED BY THE UNIVERSITY) I accept all academic and financial responsibility for the courses in which I am hereby requesting enrollmant. I have checked my addresses on the preceeding pages for accuracy and completeness. I realize that my tuition and fees are due within 30 days of the date on my bill and that if I do not pay within that time, any remaining balance is subject to a 1.5% per month finance charge. YES NO

School of Medicine Home

School of Medicine, 1430 Tulane Avenue, New Orleans, LA 70112
Phone: (504) 988-5187 Fax: (504) 988-6462