Faculty Information Form - Wayne State University

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Fields with asterisks (*) are required.

Program Name *

Preferred First Name/Nickname *

Last Name *

Full Legal Name (as on passport) *

Current Address

E-mail Address *

**Most correspondence from our office will be via e-mail. Please list one you check regularly.**

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Country *

Phone Number *

Please provide the phone number you can be reached at during the program. *

Country of Citizenship *

**Please note: If you are not a US Citizen, it is your responsibility to obtain a visa to enter the country you will be visiting. Not all programs require a visa so check online or with an advisor if you are uncertain.

WSU PID # *

Date of Birth *

Gender *

Male

Female

Emergency Contact:

Please list who should be notified in case of emergency

First Name *

Last Name *

Relationship to you *

Address line 1 *

Address line 2

City *

State/province/region *

Postal/zip code *

Cell Phone *

Home Phone

Work Phone

Fax (optional)

E-mail Address *