<h2>We want to hear from you!</h2> <h3>Stay Connected: Alumni Information Form</h3> <br /><br /><span class="xsubheader">We want to hear from you! Please complete the form below to inform us of a name change, new phone number or address, marriage, birth, or new job/promotion. We look forward to learning about you.</span><input name="recipient" type="hidden" value="mmarsho@siue.edu" /><input name="required" type="hidden" value="last name, first name, middle name, maiden name, SIUE Class Year(s), SIUE Degree(s)/Major(s), e-mail, last name, first name, middle name, maiden name, SIUE Class Year(s), SIUE Degree(s)/Major(s), e-mail, address, city, state, country, zip code, home telephone, job title, company name, address, city, state, zip code, work telephone, news" /><input name="redirect" type="hidden" value="http://www.siue.edu/business/contactus/thankyou.html" /><br /><br /> <h3>1. Privacy Information (Please check one)</h3> <table border="0" cellpadding="0" cellspacing="0"> <tbody> <tr> <td width="793"><input name="extras222" type="checkbox" value="Yes! I want my e-mail address to be included in the Alumni Online Directory listed on the SIUE Alumni website." />Yes! I want my e-mail address to be included in the Alumni Online Directory listed on the SIUE Alumni website.</td> </tr> <tr> <td><input name="extras22" type="checkbox" value="Yes! I would like to receive occasional emails announcing new benefits and events. " />Yes! I would like to receive occasional emails announcing new benefits and events.</td> </tr> <tr> <td><input name="extras22" type="checkbox" value="Please update my information with the alumni office only. I do not want my name and e-mail address to appear on the Alumni Online Directory." />Please update my information with the alumni office only. I do not want my name and e-mail address to appear on the Alumni Online Directory.</td> </tr> </tbody> </table> <p></p> <table border="0" cellpadding="5" cellspacing="0"> <tbody> <tr> <td> <h3>2. Your Information</h3> </td> </tr> <tr> <td><input name="last name" size="50" type="text" /><br /> <span class="xbodytext">Last Name</span></td> </tr> <tr> <td><input name="first name" size="50" type="text" /><br /> <span class="xbodytext">First Name</span></td> </tr> <tr> <td><input name="middle name" size="50" type="text" /><br /> <span class="xbodytext">Middle Name</span></td> </tr> <tr> <td><span class="xbodytext"><input name="maiden name" size="50" type="text" /></span><br /> <span class="xbodytext">Maiden Name</span></td> </tr> <tr> <td> <table border="0" cellpadding="0" cellspacing="0"> <tbody> <tr> <td width="60"><input name="extras2222" type="checkbox" value="Mr." />Mr.</td> <td width="70"><input name="extras2222" type="checkbox" value="Miss." />Miss.</td> </tr> <tr> <td><input name="extras223" type="checkbox" value="Mrs. " />Mrs.</td> <td><input name="extras223" type="checkbox" value="Dr. " />Dr.</td> </tr> <tr> <td><input name="extras223" type="checkbox" value="Ms." />Ms.</td> <td></td> </tr> </tbody> </table> </td> </tr> <tr> <td><span class="xbodytext"><input name="SIUE Class Year(s)" size="50" type="text" /></span><br /> <span class="xbodytext">SIUE Class Year(s)</span></td> </tr> <tr> <td> <p class="xbodytext"><input name="SIUE Degree(s)/Major(s)" size="50" type="text" /><br /> SIUE Degree(s)/Major(s)</p> </td> </tr> <tr> <td><span class="xbodytext"><input name="e-mail" size="50" type="text" /><br /> E-mail</span></td> </tr> <tr> <td> <br /> <br /> <h3>3. Spouse Information</h3> </td> </tr> <tr> <td><input name="extras2" type="checkbox" value="Yes! My spouse is an alumna/us." />Yes! My spouse is an alumna/us.</td> </tr> </tbody> </table> <table border="0" cellpadding="5" cellspacing="0"> <tbody> <tr> <td><input name="last name" size="50" type="text" /><br /> <span class="xbodytext">Last Name</span></td> </tr> <tr> <td><input name="first name" size="50" type="text" /><br /> <span class="xbodytext">First Name</span></td> </tr> <tr> <td><input name="middle name" size="50" type="text" /><br /> <span class="xbodytext">Middle Name</span></td> </tr> <tr> <td><span class="xbodytext"><input name="maiden name" size="50" type="text" /></span><br /> <span class="xbodytext">Maiden Name</span></td> </tr> <tr> <td> <table border="0" cellpadding="0" cellspacing="0"> <tbody> <tr> <td width="60"><input name="extras2222" type="checkbox" value="Mr." />Mr.</td> <td width="70"><input name="extras2222" type="checkbox" value="Miss." />Miss.</td> </tr> <tr> <td><input name="extras223" type="checkbox" value="Mrs. " />Mrs.</td> <td><input name="extras223" type="checkbox" value="Dr. " />Dr.</td> </tr> <tr> <td><input name="extras223" type="checkbox" value="Ms." />Ms.</td> <td></td> </tr> </tbody> </table> </td> </tr> <tr> <td><span class="xbodytext"><input name="SIUE Class Year(s)" size="50" type="text" /></span><br /> <span class="xbodytext">SIUE Class Year(s)</span></td> </tr> <tr> <td> <p class="xbodytext"><input name="SIUE Degree(s)/Major(s)" size="50" type="text" /><br /> SIUE Degree(s)/Major(s)</p> </td> </tr> <tr> <td><span class="xbodytext"><input name="e-mail" size="50" type="text" /><br /> E-mail</span></td> </tr> <tr> <td> <h3><br /> 4. Mailing Address</h3> </td> </tr> <tr> <td></td> </tr> </tbody> </table> <table border="0" cellpadding="5" cellspacing="0"> <tbody> <tr> <td><input name="address" size="50" type="text" /><br /> <span class="xbodytext">Address</span></td> </tr> <tr> <td><span class="xbodytext"><input name="city" size="50" type="text" /><br /> City</span></td> </tr> <tr> <td><span class="xbodytext"><input name="state" size="50" type="text" /><br /> State</span></td> </tr> <tr> <td><span class="xbodytext"><input name="country" size="50" type="text" /></span><br /> <span class="xbodytext">Country</span></td> </tr> <tr> <td> <p class="xbodytext"><input name="zip code" size="50" type="text" /><br /> Zip Code</p> </td> </tr> <tr> <td><span class="xbodytext"><input name="home telephone" size="50" type="text" /><br /> Home Telephone</span></td> </tr> <tr> <td><span class="xbodytext"><input name="cell phone" size="50" type="text" /><br /> Cell Phone</span></td> </tr> <tr> <td> <br /> <h3>5. Business Information</h3> </td> </tr> <tr> <td><span class="xbodytext"><input name="job title" size="50" type="text" /></span><br /> <span class="xbodytext">Job Title</span></td> </tr> <tr> <td> <p class="xbodytext"><input name="company name" size="50" type="text" /><br /> Company Name</p> </td> </tr> <tr> <td><span class="xbodytext"><input name="address" size="50" type="text" /><br /> Address</span></td> </tr> <tr> <td><span class="xbodytext"><input name="city" size="50" type="text" /><br /> City</span></td> </tr> <tr> <td><span class="xbodytext"><input name="state" size="50" type="text" /><br /> State</span></td> </tr> <tr> <td><span class="xbodytext"><input name="zip code" size="50" type="text" /><br /> Zip Code</span></td> </tr> <tr> <td><span class="xbodytext"><input name="work telephone" size="50" type="text" /><br /> Work Telephone</span></td> </tr> <tr> <td></td> </tr> <tr> <td> <br /> <h3>6. Tell us your news</h3> </td> </tr> <tr> <td><span class="xbodytext"><input name="news" size="50" type="text" /></span></td> </tr> <tr> <td></td> </tr> <tr> <td><input type="submit" value="Submit" /><br /> <br />&nbsp;</td> </tr> </tbody> </table> <!--End Center--><!--Begin Right Column-->