Exit Photo Request Form by llf87114


									                                                                              School of Medicine
                                                                              Graduate Studies Program
                                                                              Exit Photo Request Form
The information on this form will be used to create the title card for the Graduate Studies Class photo that will be hung in the Richard Jones Hall. You may
request your photo not be included in this class photo by sending and email to somgrad@ohsu.edu. In the subject line note ‘Class Photo Opt-Out’ and state in
the body of the email that you do not wish your photo included.
                                                                                                                                       STUDENT ID NUMBER

 Full Name
                               Last (Family) Name                                  First                          Middle

Degree Select Degree

Program Select Graduate Program

Photograph Options:

     Head shot photo via Internet file transfer (JPEG only) to somgrad@ohsu.edu
          Place your name and ‘class photo’ in the subject line.
          The photo must be of good quality and with a plain background, similar in style to a Passport Photo
          Please do not send photographs with other people, animals or distracting backgrounds.
          Photo may be color or black and white

     A photo from the OHSU Photography & Graphic Design

             Make an appointment by calling 503-494-8040 and take this form to the appointment

                  School of Medicine Exit Photo (black & white image digital image)                               $20.00

                  Internet file transfer (JPEG) to their OHSU Outlook email account                               No Charge
                  EMAIL ADDRESS

             Single Reprint (2 x 3 black and white)                                                             $ 5.00

             Photography accepts personal checks, visa or master card. The yellow copy of your receipt is to be sent to
             Graduate Studies at Mail Code L102.
             Your graduate program or mentor may agree to cover the cost of your exit photograph. Please request the
             following information prior to the appointment.

                     ALIAS #                                                      FAID#

          You will receive a receipt for your payment. Please submit the yellow copy of the receipt to:
          Graduate Studies
          Mackenzie Hall, Rm 4135
          Mail code: L102

Office of Graduate Studies                                                Ver 3                                                         February 2010

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