<h2><script type="text/javascript" src="alumni_ambassadors_signup.js" language="JavaScript"><!----></script><span class="header">Sign up to become an SIUE Alumni Ambassador</span></h2>
<p class="xbodytext">Just click in the text boxes and type the information.</p>
<p class="xbodytext"><strong><span class="clrA">*</span> Required Fields</strong></p>
<form name="AlumniAmbassadorForm" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post">
<input name="recipient" type="hidden" value="tsiripa@siue.edu" /><input name="email" type="hidden" value="tsiripa@siue.edu" /><input name="subject" type="hidden" value="Alumni Ambassador Registration" /><input name="redirect" type="hidden" value="http://www.admissions.siue.edu/AlumniAmbassadorsProgram/alumniresponse.htm" />
<table border="0" width="330" class="xbodytext" cellspacing="5" cellpadding="0">
<tr>
<td width="107">First name:</td>
<td width="208"><input name="FirstName" size="28" maxlength="40" type="text" id="FirstName" /><span class="clrA">*</span></td>
</tr>
<tr>
<td>Last Name:</td>
<td><input name="LastName" size="28" maxlength="40" type="text" id="LastName" /><span class="clrA">*</span></td>
</tr>
<tr>
<td>Address:</td>
<td><input name="Address" size="28" maxlength="40" type="text" id="Address" /><span class="clrA">*</span></td>
</tr>
<tr>
<td>City:</td>
<td><input name="City" size="28" maxlength="40" type="text" id="City" /><span class="clrA">*</span></td>
</tr>
<tr>
<td>State:</td>
<td><select name="State" id="State"><option selected="selected">Select State</option> <option value="Alabama">Alabama</option> <option value="Alaska">Alaska</option> <option value="Arizona">Arizona</option> <option value="Arkansas">Arkansas</option> <option value="California">California</option> <option value="Colorado">Colorado</option> <option value="Connecticut">Connecticut</option> <option value="Delaware">Delaware</option> <option value="Florida">Florida</option> <option value="Georgia">Georgia</option> <option value="Hawaii">Hawaii</option> <option value="Idaho">Idaho</option> <option value="Illinois">Illinois</option> <option value="Indiana">Indiana</option> <option value="Iowa">Iowa</option> <option value="Kansas">Kansas</option> <option value="Kentucky">Kentucky</option> <option value="Louisiana">Louisiana</option> <option value="Maine">Maine</option> <option value="Maryland">Maryland</option> <option value="Massachusetts">Massachusetts</option> <option value="Michigan">Michigan</option> <option value="Minnesota">Minnesota</option> <option value="Mississippi">Mississippi</option> <option value="Missouri">Missouri</option> <option value="Montana">Montana</option> <option value="Nebraska">Nebraska</option> <option value="Nevada">Nevada</option> <option value="NewHampshire">New Hampshire</option> <option value="NewJersey">New Jersey</option> <option value="NewMexico">New Mexico</option> <option value="NewYork">New York</option> <option value="NorthCarolina">North Carolina</option> <option value="NorthDakota">North Dakota</option> <option value="Ohio">Ohio</option> <option value="Oklahoma">Oklahoma</option> <option value="Oregon">Oregon</option> <option value="Pennsylvania">Pennsylvania</option> <option value="RhodeIsland">Rhode Island</option> <option value="SouthCarolina">South Carolina</option> <option value="SouthDakota">South Dakota</option> <option value="Tennessee">Tennessee</option> <option value="Texas">Texas</option> <option value="Utah">Utah</option> <option value="Vermont">Vermont</option> <option value="Virginia">Virginia</option> <option value="Washington">Washington</option> <option value="WashingtonDC">Washington, D.C.</option> <option value="WestVirginia">West Virgina</option> <option value="Wisconsin">Wisconsin</option> <option value="Wyoming">Wyoming</option> </select> <span class="clrA">*</span></td>
</tr>
<tr>
<td>ZIP:</td>
<td><input name="ZIP" size="5" maxlength="5" type="text" id="ZIP" /><span class="clrA">*</span></td>
</tr>
<tr>
<td>E-mail Address:</td>
<td><input name="EmailAddress" size="28" maxlength="30" type="text" id="EmailAddress" /><span class="clrA">*</span></td>
</tr>
<tr>
<td>Graduation Year:</td>
<td><input name="GraduationYear" size="28" maxlength="28" type="text" id="GraduationYear" /><span class="clrA">*</span></td>
</tr>
<tr>
<td>Major at SIUE</td>
<td><input name="Major" size="28" maxlength="28" type="text" id="Major" /><span class="clrA">*</span></td>
</tr>
<tr>
<td>Phone Number:</td>
<td><input name="Phone" size="15" maxlength="15" type="text" id="Phone" /><span class="clrA">*</span></td>
</tr>
<tr>
<td colspan="2">
<p></p>
<p>I would be interested in volunteering for the following:<br /> (check all that apply)</p>
</td>
</tr>
<tr valign="top" align="left">
<td colspan="2"><input name="CollegeFairs" type="checkbox" value="Yes" id="CollegeFairs" />Representing SIUE at local college fairs.</td>
</tr>
<tr valign="top" align="left">
<td colspan="2"><input name="StudentReceptions" type="checkbox" value="Yes" id="StudentReceptions" />Attending admitted student receptions.</td>
</tr>
<tr valign="top" align="left">
<td colspan="2"><input name="PhoneCallsAndEmails" type="checkbox" value="Yes" id="PhoneCallsAndEmails" />Making congratulatory phone calls and/or sending e-mails to students.</td>
</tr>
<tr valign="top" align="left">
<td colspan="2"><input name="Chats" type="checkbox" value="Yes" id="Chats" />Participating in on-line chat sessions with prospective students.</td>
</tr>
<tr valign="top" align="left">
<td colspan="2"><input name="InformationPanels" type="checkbox" value="Yes" id="InformationPanels" />Serve on informational panels during visit days or new student programs.</td>
</tr>
<tr valign="top" align="left">
<td colspan="2"><input name="HelpWithScholarshipInterviews" type="checkbox" value="Yes" id="HelpWithScholarshipInterviews" />Help with Scholars Interview Day.</td>
</tr>
<tr>
<td colspan="2">
<p></p>
<p><input name="Submit" onclick="MM_validateForm('FirstName','','R','LastName','','R','Address','','R','City','','R','ZIP','','RisNum','EmailAddress','','RisEmail','GraduationYear','','R','Major','','R','Phone','','R');return document.MM_returnValue" type="submit" value="Sign Me Up" /><span class="rtbodytext"><br /> (Please click once, then wait for the response.)</span></p>
<p><br /> <input name="Reset" type="reset" value="Clear Form" /></p>
</td>
</tr>
</table>
</form>