Embassy of the United States Phnom Penh, Cambodia

Alumni Records Update Form
Please inform us of any changes to your address, job, e-mail, etc. by submitting this form to the address:
Public Affairs Section, American Embassy: #1, Street 96

Privacy Policy: The data is being collected by the U.S. Embassy Phnom Penh and will be used to stay in touch with participants of U.S Government-Sponsored Exchange Programs. We do not release information to any outside companies, organizations, or governments, nor to any third parties not directly involved with exchange programs administered by the Bureau of Educational and Cultural Affairs.

First Name:
Check one: Mr., Mrs., Other:  
Date of Birth: Country of Birth:
Country of Citizenship 1st: 2nd (if any):
Have you been a member of State Alumni Website? (Check one) Yes / No
If No, please visit https://alumni.state.gov/login/  
Preferable mailing address (check one): Office, Home

I. HOME ADDRESS

Residential Address:
Phone No.: Fax No.: Email Address:

II. BUSINESS ADDRESS

Business name: Since:
Title: Divison/Department:
Business Address:
Business Phone No.: Business Fax No.:
Business Email Address.:

III. PROGRAM INFORMATION

Program participated: Please check one: International Visitors, Humphrey or Fulbright
Subject or field of study:
Program start date: (month/Year)
Program end date: (Month/Year)
What institution(s) or university did you study at? (If applies):
U.S. City (or cities) visited while on your program:

IV. ENGLISH PROFICIENCY

Speaking: Reading: Comprehension:
0 = No Proficiency, 1 = Elementary Proficiency, 2 = Limited Working Proficiency, 3 = General Professional Proficiency, 4 = Advanced Professional Proficiency and 5 = Native or Bilingual Proficiency.

Many thanks for your participation!