2006 Alumni Dir=
ectory
Form
The UCLA Department of
Ophthalmology Association recently published an updated 2006 Alumni Directo=
ry. Please complete this form and ret=
urn it
at the address(es) listed below if you would like to submit new contact
information or update the information printed in the directory or posted on=
the
JSEI website. Please notify us in writing if you=
DO
NOT want to be included in the directory.
Name
Spouse or Partner nam=
e (if
applicable):________________________________________________
Did you complete your=
residency at JSEI?
=
Yes =
No
What year(s) did you =
attend? &=
nbsp; &nbs=
p; First
Year: _________ Last Year:
_________ =
Did you complete a
What year(s) did you =
attend? &=
nbsp; &nbs=
p; First
Year: _________ Last Year:
_________ =
Please indicate your =
practice
specialty ________________________________________________
Business Address: =
_______________________________=
_____________________________
City, State, Zip &=
nbsp; ____________________________________________=
________________
Business Phone Number:
___________________________________________________________
Business Fax Number:<=
span
style=3D"mso-spacerun: yes">
___________________________________________________________
Home
City, State, Zip &=
nbsp; ____________________________________________=
________________
Home Phone Number:
E-Mail<=
span
style=3D'font-size:11.0pt'> Address: &=
nbsp; ______________=
______________________________________________
Web Address: =
_=
___________________________________________________________
Photograph - <=
/span>We would like to publish a current photograph of=
each
member along with their contact information. If you would like to submit an individual headshot or
replace the current image on file, please e-mail your image (300 dpi) to al=
umni@jsei.ucla.edu.
UCLA Department of Ophthalmology Associati=
on
Jules Stein Eye Institute, 100 Stein Plaza, UCLA=
, Room
1-124,
Los Angeles, California 90095-7000
Phone:
310-825-4148, Fax:
310-794-7781, E-Mail: alumni@jsei.ucla.edu
UCLA DEPARTMENT OF OPHTHALMOLOGY
ASSOCIATION
JULES STEIN EYE INSTITUTE
DAVID GEFFEN SCHOOL OF MEDICINE=
AT
UCLA
100 STEIN PLAZA, ROOM 1-124
LOS ANGELES, CALIFORNIA 90095-7=
000