<h2>Contact Page</h2>
<h3>We want to hear from you!<br /><span class="xsubheader"><br /></span></h3>
<p class="clrA"><span class="xsubheader">SON Information Request<br /></span> <span style="color:#FF0000">*</span><span class="clrA"><span class="xcaption"><span class="clrA">Required Information</span></span></span></p>
<form name="mail" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post">
<p><input name="recipient" type="hidden" value="nschibe@siue.edu" /><input name="required" type="hidden" value="email,realname, address, city-state-zip, home phone, expected entry date" /><input name="redirect" type="hidden" value="http://www.siue.edu/NURSING/contactus/thankyou.html" /></p>
<table border="0" cellpadding="5" cellspacing="0">
<tbody>
<tr>
<td><input name="realname" size="50" type="text" /><br /> <span style="color:#FF0000">*</span><span class="xbodytext">Name While Attending SIUE</span></td>
</tr>
<tr>
<td><span class="xbodytext"><input name="address" size="50" type="text" /><br /> <span style="color:#FF0000">*</span>Address</span></td>
</tr>
<tr>
<td><span class="xbodytext"><input name="city-state-zip" size="50" type="text" /><br /> <span style="color:#FF0000">*</span>City/State/Zip</span></td>
</tr>
<tr>
<td><span class="xbodytext"><input name="county" size="50" type="text" /></span><br /> <span class="xbodytext">County</span></td>
</tr>
<tr>
<td>
<p class="xbodytext"><input name="home phone" size="50" type="text" /><br /> <span style="color:#FF0000">*</span>Home Phone</p>
</td>
</tr>
<tr>
<td><span class="xbodytext"><input name="work phone" size="50" type="text" /><br /> Work Phone</span></td>
</tr>
<tr>
<td><span class="xbodytext"><input name="cell phone" size="50" type="text" /><br /> Cell Phone</span></td>
</tr>
<tr>
<td><span class="xbodytext"><input name="expected entry date" size="50" type="text" /><br /> <span style="color:#FF0000">*</span>Graduation date: 00/00</span></td>
</tr>
<tr>
<td><span class="xbodytext"><input name="email" size="50" type="text" /><br /> <span style="color:#FF0000">*</span>E-mail address</span></td>
</tr>
<tr>
<td>
<br /> <br />
<table border="0" cellpadding="0" cellspacing="0">
<tbody>
<tr>
<td></td>
</tr>
<tr>
<td valign="top"><span class="xbodytext"><span class="clrA">*</span>Please enter your news here.</span> <br /> <textarea name="comments" rows="15" cols="75" id="comments"></textarea></td>
</tr>
<tr>
<td></td>
</tr>
<tr>
<td><input type="submit" value="Submit" /><br /> <br /> </td>
</tr>
</tbody>
</table>
<p><br /></p>
</td>
</tr>
</tbody>
</table>
</form>