Chapter Interest Form

Thank you for your interest in Western Alumni. Please complete the form below with your contact information and your Chapter of interest.

Please indicate which chapter/group is of interest to you.

BAWA (Black at Western Alumni Chapter)

Asian Alumni Network

Indigenous Alumni Chapter

Which type of events are you interested in attending

Were you involved with any clubs or athletics while you were a student at Western?

Yes No

Please tell us who you are

Title

First Name Do you have a preferred name?

Middle Name

Last Name

Name while attending Western

Student or Alumni Number
Where can I find my alumni number?

- OR -

Degree

Graduation Year

Home Address

Street Address 1

Street Address 2

City

Province/State

Country/Region

Postal/Zip Code

Home Phone
Numbers only (eg. 5195551234)

Mobile Phone
Numbers only (eg. 5195551234)

Work Address

Position Title

Company Name

Work Address 1

Work Address 2

City

Province/State

Country/Region

Postal/Zip Code

Work Phone Numbers only (eg. 5195551234)

Social Media

Twitter Handle

Facebook Username

Instagram Username

LinkedIn URL

WeChat ID

The information provided above will be used to update your Western alumni record. Please read Western's Privacy Policy if you wish to learn about how the University protects and uses your information.

Western University, Department of Alumni Relations & Development
Westminster Hall, Suite 110
London, Ontario, Canada, N6A 3K7
Toll-free: 1-800-258-6896
alumni@uwo.ca