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<h2>Alumni Ambassadors</h2>
<h3>Refer a Student to SIUE</h3>
<p class="style5">Just select the text in the boxes and type the information.</p>
<p class="style5"><span class="style1">*</span> Required Fields</p>
<form onsubmit="return checkFieldsStudentReferral();" name="form" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post" id="AlumniAmbassadorStudentReferral">
<input name="recipient" type="hidden" value="tforys@siue.edu" /><input name="email" type="hidden" value="tforys@siue.edu" /><input name="subject" type="hidden" value="Alumni Ambassador Student Referral" /><input name="redirect" type="hidden" value="http://www.siue.edu/alumni/ambassadors/alumni_ambassadors_student_referral_thankyou.shtml" />
<p><input name="a_01_student_first_name" onkeypress="return handleEnter(this, event)" maxlength="35" size="48" value=" Prospective Student's First Name" onfocus="this.select()" id="a_01_student_first_name" align="middle" /><span class="style1">*</span></p>
<p><input name="a_02_student_last_name" onkeypress="return handleEnter(this, event)" maxlength="35" size="48" value=" Last Name" onfocus="this.select()" id="a_02_student_last_name" align="middle" /><span class="style1">*</span></p>
<p><input name="a_04_student_address" onkeypress="return handleEnter(this, event)" maxlength="45" size="48" value=" Address" onfocus="this.select()" id="a_04_student_address" /><span class="style1">*</span></p>
<p><input name="a_05_student_city" onkeypress="return handleEnter(this, event)" maxlength="45" size="48" value=" City" onfocus="this.select()" id="a_05_student_city" /><span class="style1">*</span></p>
<p><select name="a_06_student_state" id="a_06_student_state"><option selected="selected">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="style1">*</span> <input name="a_07_student_zip" maxlength="5" size="20" value=" ZIP" onfocus="this.select()" id="a_07_student_zip" /> <span class="style1">*</span></p>
<p><input name="a_09_student_dob" onkeypress="return handleEnter(this, event)" maxlength="42" size="48" value=" Date of Birth (mm/dd/yyyy)" onfocus="this.select()" id="a_09_student_dob" /><span class="style1">*</span></p>
<p><input name="a_10_student_day_phone" onkeypress="return handleEnter(this, event)" maxlength="42" size="48" value=" Day Phone" onfocus="this.select()" id="a_10_student_day_phone" /></p>
<p><input name="a_11_student_evening_phone" onkeypress="return handleEnter(this, event)" maxlength="42" size="48" value=" Evening Phone" onfocus="this.select()" id="a_11_student_evening_phone" /></p>
<p><input name="a_12_student_email" onkeypress="return handleEnter(this, event)" maxlength="42" size="48" value=" E-mail Address" onfocus="this.select()" id="a_12_student_email" /><span class="style1">*</span></p>
<p><input name="a_13_student_last_hs_or_college" onkeypress="return handleEnter(this, event)" maxlength="42" size="48" value=" High School or College Last Attended" onfocus="this.select()" id="a_13_student_last_hs_or_college" /><span class="style1">*</span></p>
<p><select name="a_14_student_grad_month" size="1" id="a_14_student_grad_month"><option value="Graduation Month">Graduation Month</option> <option value="January">January</option> <option value="February">February</option> <option value="March">March</option> <option value="April">April</option> <option value="May">May</option> <option value="June">June</option> <option value="July">July</option> <option value="August">August</option> <option value="September">September</option> <option value="October">October</option> <option value="November">November</option> <option value="December">December</option> </select> <select name="a_15_student_grad_year" size="1" id="a_15_student_grad_year"> <option value="Graduation Year">Graduation Year</option> <option value="2006">2006</option> <option value="2007">2007</option> <option value="2008">2008</option> <option value="2009">2009</option> <option value="2010">2010</option> </select><span class="style1">*</span></p>
<p><select name="a_16_student_year_start_college" size="1" id="select5"><option value="year_college">Year Student Plans to Begin College</option> <option value="2006">2006</option> <option value="2007">2007</option> <option value="2008">2008</option> <option value="2009">2009</option> <option value="2010">2010</option> </select><span class="style1">*</span></p>
<p><select name="a_17_student_term_start_college" size="1" id="select4"><option value="Term Student Plans to Begin College">Term Student Plans to Begin College</option> <option value="fall">fall</option> <option value="spring">spring</option> <option value="summer">summer</option> </select><span class="style1">*</span></p>
<p><strong>Please send the student:</strong> <span class="style5">(check all that apply)</span></p>
<p class="style5"><input name="b_01_fin_aid_scholarship" type="checkbox" value="Financial Aid, Scholarship Brochure" id="b_01_fin_aid_scholarship" />Financial Aid and Scholarship Brochure</p>
<p class="style5"><input name="b_02_housing" type="checkbox" value="Housing Information" id="b_02_housing" />University Housing Information</p>
<p class="style5"><input name="b_03_scholarship_app" type="checkbox" value="Scholarship Application" id="b_03_scholarship_app" />Scholarship Application</p>
<p class="style5"><input name="b_04_army_rotc_info" type="checkbox" value="Army ROTC" id="b_04_army_rotc_info" />Army ROTC Information</p>
<p class="style5"><input name="b_05_air_force_rotc_info" type="checkbox" value="Air Force ROTC" id="b_05_air_force_rotc_info" />Air Force ROTC Information</p>
<p class="style5"><input name="b_06_transfer_info" type="checkbox" value="Transfer Information" id="b_06_transfer_info" />Transfer Information</p>
<p class="style5"><input name="b_07_visit_information" type="checkbox" value="Visit Information" id="b_07_visit_information" />Visit Information</p>
<p><textarea name="b_08_information_about" rows="3" cols="48" onfocus="boxFocused(this.name);" id="b_08_information_about">Information About ...</textarea></p>
<p><input name="c_01_alum_name" onkeypress="return handleEnter(this, event)" maxlength="42" size="48" value=" Referring Alum's Name" onfocus="this.select()" id="c_01_alum_name" /><span class="style1">*</span></p>
<p><input name="c_02_alum_phone" onkeypress="return handleEnter(this, event)" maxlength="42" size="48" value=" Referring Alum's Phone" onfocus="this.select()" id="c_02_alum_phone" /></p>
<p><input name="c_03_alum_email" onkeypress="return handleEnter(this, event)" maxlength="42" size="48" value=" Referring Alum's E-mail" onfocus="this.select()" id="c_03_alum_email" /><span class="style1">*</span></p>
<p>Are you an SIUE Alumni Ambassador? <input name="SIUEAmbassador" type="radio" value="Yes" /> Yes <input name="SIUEAmbassador" type="radio" value="No" /> No</p>
<p><input name="Submit" type="submit" value="Refer Student" /><br /> <span class="rtbodytext style5">(Please click once, then wait for the response.)</span></p>
<p><span class="rtbodytext"><input name="Reset1" type="reset" value="Clear Form" /></span></p>
</form>