Counselor Contact Update Form

Contact Information:

Salutation

First Name*

Last Name*

Email Address*

Office Phone Number*

Does your phone require an extension?

Yes

No

Extension

Organization Information:

Organization Type*

School / Institution

School / Institution Name*

Office / Department

Working Title*

Community Based Organization (CBO)

CBO Name*

Independent Counselor

Organization*

Organization Address*

Country

Street

City

Region

Postal Code

Have you visited UCI?

Yes

No

Are you a UCI alum?

Yes

No

Optional Information:

When did you start working for your current organization? (MM-dd-yyyy)

Which populations of students do you serve?

Scheduling:

Are you the contact at your organization who schedules college reps to visit your school?

Yes

No

How does your school schedule college reps to visit?

Please provide scheduling website:

Please provide information on your scheduling method preferences: