Office of Marketing and Communications
4170 City Avenue
Philadelphia, PA 19131
215-871-6300

Publicity Information

PLEASE COMPLETE ALL REQUESTED INFORMATION
This information is needed by June 25, 2010
At your request, the Office of Marketing and Communications will send a press release announcing your graduation to two hometown newspapers and the alumni magazine of your alma mater.

Please have all information available before you start to enter the information on this form. You will not be able to save your entry and go back to complete it.

Once you hit the SUBMIT button at the bottom of the form, your information will be sent to the Office of Marketing and Communications. You will receive a proof of your press release at your PCOM e-mail address. For your press release to be forwarded to the publications you have indicated, you MUST reply to the e-mail from your PCOM e-mail account confirming this information is correct or with corrections to suen@pcom.edu.

Name and Address

Your PCOM email address:

First Name:

Middle Name:

Last Name:

Suffix:

Male
Female

Phone Number

Your current phone number:

Your Hometown

Hometown City :

Hometown State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Family Information

Press releases usually state that the student “is the son (daughter) of John and Mary Doe, Everywhere, Pennsylvania.” Please indicate the family member(s) and city/state of the individual(s) you would like mentioned.

***The following must be completed to name a Mother***

Mother's name:

Mother's city:

Mother's state: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

***The following must be completed to name a Father***

Father's name:

Father's city:

Father's state: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

***The following must be completed to name a Step Mother***

Step Mother's name:

Step Mother's city:

Step Mother's state: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

***The following must be completed to name a Step Father***

Step Father's name:

Step Father's city:

Step Father's state: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

***The following must be completed to name another family member***

Other family member's name:

Other family member's relationship:

Other family member's city:

Other family member's state: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Program Information

Psy.D Clinical Psychology
Psy.D School Psychology
MS Biomedical Sciences
MS Forensic Medicine
MS Organizational & Development
MS Counseling and Clinical Health Psychology
MS School Psychology
MS Physicians Assistant Studies
EDS School Psycholgy

Undergraduate Information

Name of Undergraduate institution:

Year of Undergraduate degree:

Undergraduate degree:

Major of Undergraduate degree:

***The following must be completed to forward this information to the publication of your choice***

Graduate Institution Information

Name of graduate institution:

Year of graduate degree:

Graduate degree:

Major of graduate degree:

***The following must be completed to forward this information***

Name of graduate alumni publication:

Graduate institution street address:

Graduate institution street address second line:

Graduate institution city:

Graduate institution state: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Graduate institution ZIP:

Newspaper Notification

***The following must be completed to forward this information to the newspaper of your choice***

Name of hometown newspaper:

Hometown newspaper mailing street address first line:

Hometown newspaper mailing street address second line:

Hometown newspaper city:

Hometown newspaper state: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Hometown newspaper ZIP:

***The following must be completed to forward this information to the newspaper of your choice***

Name of second hometown newspaper:

Second hometown newspaper mailing street address first line:

Second hometown newspaper mailing street address second line:

Second hometown newspaper city:

Second hometown newspaper state: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Second hometown newspaper ZIP: