<script type="text/javascript" src="parent_form.js" language="JavaScript"><!----></script>
<table border="0" width="500" cellpadding="0" cellspacing="0">
<tr>
<td>
<h3>Please tell us what you would like to see on the Web site:</h3>
<form name="Counselor_Feedback" action="http://www.siue.edu/cgi-bin/FormMail.pl">
<input name="recipient" type="hidden" value="ddennis@siue.edu" /><input name="email" type="hidden" value="ddennis@siue.edu" /><input name="subject" type="hidden" value="Parent Connection" /><input name="redirect" type="hidden" value="http://www.siue.edu/prospectivestudents/parents_feedback_response.shtml" />
<table width="100%" cellspacing="5" cellpadding="0">
<tr>
<td width="300">
<div align="right">Name:</div>
</td>
<td><input name="a01_Name" size="40" type="text" value="Optional" onfocus="boxFocused(this.name);" id="a01_Name" /></td>
</tr>
<tr>
<td width="300">
<div align="right">Titile:</div>
</td>
<td><input name="a02_Titile" size="40" type="text" value="Optional" onfocus="boxFocused(this.name);" id="a02_Titile" /></td>
</tr>
<tr>
<td width="300">
<div align="right">Institution</div>
</td>
<td><input name="a03_Intstitution" size="40" type="text" value="Optional" onfocus="boxFocused(this.name);" id="a03_Intstitution" /></td>
</tr>
<tr>
<td width="300">
<div align="right">E-mail Address</div>
</td>
<td><input name="a04_email" size="40" type="text" onfocus="boxFocused(this.name);" id="a04_email" /></td>
</tr>
<tr>
<td width="300">
<div align="right">Phone Number</div>
</td>
<td><input name="a05_Phone" size="12" maxlength="12" type="text" value="Optional" onfocus="boxFocused(this.name);" id="a05_Phone" /></td>
</tr>
<tr>
<td width="300">
<div align="right">What would you like to see on the Web Site?</div>
</td>
<td>
<div align="left"><input name="a06_What_I_want_to_see" size="40" type="text" onfocus="boxFocused(this.name);" id="a06_What_I_want_to_see" /></div>
</td>
</tr>
<tr>
<td width="300">
<div align="right">Report any Web problems that you had/found</div>
</td>
<td>
<div align="left"><input name="a07_Report_Error" size="40" type="text" onfocus="boxFocused(this.name);" id="a07_Report_Error" /></div>
</td>
</tr>
</table>
<p align="left"><input name="Submit" type="submit" value="Submit" /> (Please click only once and wait for the response page.)<br /><br /><input name="Reset" type="reset" value="Reset" /></p>
</form>
</td>
</tr>
</table>