Directory Update Request – Burrell College of Osteopathic Medicine Forms

Name:(Required)

First Last

Email:(Required)

Enter Email Confirm Email

Date for update to take effect:(Required)

Location of Information to be updated – select all that apply:(Required)

Directory Webpage

Department Webpage

Other Burrell Webpage

Department Webpage URL:(Required)

Other Burrell Webpage URL:(Required)

Name (Currently Listed As):(Required)

First Last

Name (If an Update is Needed):

First Last

Credential:

Title:

Department:

Office Number:

Email Address:

Office Phone:

Degree Information:

Comments/Questions: