Your name:

Title:

E-mail:

• Male
• Female

Degree from Cornell (check all that apply):

• BS Year:
• MS Year:
• Ph.D Year:

Address:

Tel No.:

Fax No.:

May we list your name and e-mail address on the on-line Lodge alumni list?

Yes No

Comments?

Thank you for responding to this questionnaire.

Your responses will be e-mailed to a current lodge member who will update your alumni database with your current information. All information will be kept confidential.