Personal Profile Entry Form

Title	First *	Middle *	Last Name *	[Nickname]
Mr. Ms. Mrs. Dr. Prof.
Department:			Institution:

Work Address:

  Street:

City	Prov.	Postal Code	Country

Home Address:

  Street:

City	Prov.	Postal Code	Country

	Work	Home
Phone:
FAX:
* E-mail:
Web Page:
	ICQ number:

Role:   User Editor Gender:   F M     I was born on  
and I began using the pix.imgdb on     [yyyy-mm-dd]

Shall we make your profile accessible in this Database? OK NO