Newly Promoted Emeritus Information Form

We are pleased to inform you that we are on the right path to getting the Emeritus badges distributed to everyone. To ensure we have all the necessary details, please take a moment to complete the form below at your earliest convenience. ID Badges can be mailed out or picked up in-person.

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Country Phone Number

Preferred Email

Would you like an Emeritus Badge?

Yes

For Badge, please provide the make/model of vehicle and license plate number

Would you like to keep your UAMS email?

Yes