Membership Form For Greater Gator Community UF College of Medicine A. Contact information:Date MM slash DD slash YYYY Name First Last Date of Retirement MM slash DD slash YYYY UFID* DepartmentAging and Geriatric ResearchAnatomy and Cell BiologyAnesthesiologyBiochemistry and Molecular BiologyBiostatisticsCommunity Health and Family MedicineDermatologyEmergency MedicineEpidemiologyHealth Outcomes and Biomedical InformaticsMedicineMolecular Genetics and MicrobiologyNeurologyNeuroscienceNeurosurgeryObstetrics and GynecologyOphthalmologyOrthopaedics and RehabilitationOtolaryngologyPathology, Immunology, and Laboratory MedicinePediatricsPharmacology and TherapeuticsPhysical Medicine and RehabilitationPhysiology and Functional GenomicsPsychiatryRadiation OncologyRadiologySchool of PA StudiesSurgeryUrologyDivision Work Email Alternate Email Which is your preferred email address?*Work EmailAlternate EmailCell PhoneHome PhoneHome Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country What information would you permit to be published in a directory for others in the Greater Gator Community: Work Email Alternate Email Cell Phone Home Phone Home Address Interest in attending seminarsI am interested in attending seminars from my own Division/DepartmentYesNoI am interested in attending seminars throughout the College of MedicineYesNoB. Request to become a Granite Gator ScholarAll retirees will be made members of the Greater Gator Community of the College of Medicine as Granite Gators upon completion of this form. If interested in becoming a Granite Gator Scholar, please choose the appropriate response from the dropdown list below and fill out the sections below.Request to become a Granite Gator Scholar*Select oneI am interested in becoming a Granite Gator ScholarI am NOT interested in becoming a Granite Gator ScholarPlease check the coaching/mentoring activities that you have particular expertise:* Classroom teaching, Basic Science Classroom teaching, Clinical Bedside teaching Writing a case study manuscripts Writing a retrospective study manuscripts Writing a meta-analysis study manuscripts Writing a basic science manuscripts Writing a basic science grants Writing a clinical trial grants Mitigating interpersonal issues with coworkers in the workplace Anger control issues How to resolve unprofessional behaviors in interacting with patients Writing test questions Giving seminars Balancing demands of home and work Personal finances Managing grant finances Managing Stress Navigating peer review of papers Navigating peer review of grants Other If "Other" is chosen as an expertise, please explainAre you interested in giving a seminar in your own Division/Department?*YesNoI would need a computer camera to participate in teleconferences*YesNo Please contact Mark Segal MD/PhD at email@example.com if you have any questions.