<h2>STAT Alumni Mentor Program - Mentor Participation Survey</h2><table> <tbody> <tr> <td height="245" valign="top" width="505"> <table border="0" width="460" cellspacing="0" cellpadding="0"> <tbody> <tr> <td> <p class="textbody">To participate in the STAT Alumni Mentor Program, fill out and submit this form:</p> <form name="mail" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post"> <p><input name="recipient" type="hidden" value="kabenne@siue.edu" /><input name="required" type="hidden" /><input name="redirect" type="hidden" value="http://www.siue.edu/alumni/stat/thankyou.shtml" /></p> <table border="0" width="455"> <tbody> <tr> <td class="head2a" colspan="2"> <h3 align="center">Printable Participation Survey</h3> </td> </tr> <tr> <td class="textbodybold" colspan="2"><strong>1. Your Information</strong></td> </tr> <tr> <td width="127" class="text1" align="right">Last Name</td> <td width="318"><input name="Last Name" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">First Name</td> <td><input name="First Name" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Maiden Name</td> <td><input name="Maiden Name" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Title Select title<br /></td> <td class="text1"><input name="Title" type="radio" value="Mr." />Mr. <input name="Title" type="radio" value="Mrs." /> Mrs. <input name="Title" type="radio" value="Ms." /> Ms. <input name="Title" type="radio" value="Miss." /> Miss. <input name="Title" type="radio" value="Dr." /> Dr.</td> </tr> <tr> <td class="text1" align="right">SIUE Graduation Year<br /></td> <td><input name="Graduation Year" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Degree<br /></td> <td><input name="Degree" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Major(s)</td> <td><input name="Major(s)" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">E-mail</td> <td><input name="E-mail" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Current Mailing Address</td> <td><input name="Current Mailing Address" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">City</td> <td><input name="City" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">State</td> <td><input name="State" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Zip Code</td> <td><input name="Zip Code" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Company</td> <td><input name="Company" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Job Title</td> <td><input name="Job Title" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Work Mailing Address</td> <td><input name="Work Mailing Address" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">City</td> <td><input name="Work City" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">State</td> <td><input name="Work State" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Zip Code</td> <td><input name="Work Zip Code" maxlength="30" size="30" /></td> </tr> <tr> <td class="text1" align="right">Phone Number</td> <td><input name="Phone Number" maxlength="30" size="30" /></td> </tr> <tr> <td class="textbody" colspan="2">Do you authorize the Alumni Association to release your address and phone number to your student so that he or she can contact you?<br /></td> </tr> <tr> <td class="text2" colspan="2" align="center"><input name="Release" type="radio" value="Yes" />Yes <input name="Release" type="radio" value="No" /> No</td> </tr> <tr> <td class="text1" colspan="2">Would you prefer a female or male student, or do you have a preference?<br /></td> </tr> <tr> <td class="textbody" colspan="2" align="center"><input name="Sex" type="radio" value="Female" />Female <input name="Sex" type="radio" value="Male" /> Male <input name="Sex" type="radio" value="No Preference" /> No Preference</td> </tr> <tr> <td class="text1" align="right">What was your hometown and high school when you attended SIUE?</td> <td><input name="Home town" maxlength="30" size="30" /></td> </tr> <tr> <td class="textbody" colspan="2">Did you participate in any clubs, activities or sports while at SIUE? If so, which ones?<br /></td> </tr> <tr> <td class="textbody" colspan="2" align="center"><textarea name="Did you participate in any clubs, activities or sports at SIUE? If so, which ones?" rows="8" cols="50" id="highschool"></textarea></td> </tr> <tr> <td class="textbody" colspan="2">Where do you work now? Please describe your day-to-day responsibilities.<br /></td> </tr> <tr> <td class="textbody" colspan="2" align="center"><textarea name="Where do you work now? Please describe your day-to-day responsibilities." rows="8" cols="50" id="highschool1"></textarea></td> </tr> <tr> <td class="textbody" colspan="2">Do you have any special interests or hobbies that you would like to share with your student?<br /></td> </tr> <tr> <td class="textbody" colspan="2" align="center"><textarea name="Do you have any special interests or hobbies that you would like to share with your student?" rows="8" cols="50" id="highschool2"></textarea></td> </tr> <tr> <td class="textbody" colspan="2">Do you have any children or other relatives who attended or are now attending SIUE?<br /></td> </tr> <tr> <td class="textbody" colspan="2" align="center"><textarea name="Do you have any children or other relatives who attended or are now attending SIUE?" rows="8" cols="50" id="highschool4"></textarea></td> </tr> <tr> <td class="textbody" colspan="2">Would you like to provide any other information that would assist us in making a good match?<br /></td> </tr> <tr> <td class="textbody" colspan="2" align="center"><textarea name="Would you like to provide any other information that would assist us in making a good match?" rows="8" cols="50" id="highschool3"></textarea></td> </tr> <tr> <td height="50" class="text1" colspan="2"></td> <td><input type="submit" value="Submit" /><br /></td> </tr> </tbody> </table><!--EndFragment--> </form> </td> </tr> </tbody> </table> </td> </tr> </tbody></table>