<h2>Printing Reimbursement</h2><p>Please fill out the form below to let us know about your printing problems and how much we need to reimburse your Cougar Card.<br />All fields are Required.</p><form name="mail" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post"><input name="required" type="hidden" value="name,e-id,ID,printing_problem,amount_to_reimburse" /><input name="print_blank_fields" type="hidden" value="1" /><input name="subject" type="hidden" value="Printing Problem: Cougar Card Reimbursement" /><input name="redirect" type="hidden" value="http://www.siue.edu/lovejoylibrary/ac/thanksprinting.shtml" /><input name="recipient" type="hidden" value="oac_help@siue.edu" /> <table border="0" cellspacing="0" cellpadding="2"> <tr valign="top"> <td> <div align="right"><strong>Name:</strong></div> </td> <td><label for="name"><input name="name" size="40" type="text" value="Enter Your First and Last Name" onfocus="this.value=''" id="name" /></label></td> </tr> <tr valign="top"> <td> <div align="right"><strong>University ID Number:</strong></div> </td> <td><label for="ID"><input name="ID" size="40" type="text" value="Enter Your 800 Number" onfocus="this.value=''" id="ID" /></label></td> </tr> <tr valign="top"> <td> <div align="right"><strong>e-ID:</strong></div> </td> <td><label for="e-id"><input name="e-id" size="40" type="text" value="Your e-d, e.g. jsmith" onfocus="this.value=''" id="e-id" /></label></td> </tr> <tr valign="top"> <td> <div align="right"><strong>Date and Time of Printing/Copying Problem:</strong></div> </td> <td><label for="printing_problem"><input name="printing_problem" size="60" type="text" value="Enter the Date and Time of the Printing/Copying Problem" onfocus="this.value=''" id="printing_problem" /></label></td> </tr> <tr valign="top"> <td> <div align="right"><strong>Amount to Reimburse:</strong></div> </td> <td><label for="amount_to_reimburse"><input name="amount_to_reimburse" size="60" type="text" value="Enter the Dollar Amount you need to be reimbursed" onfocus="this.value=''" id="amount_to_reimburse" /></label></td> </tr> <tr valign="top"> <td></td> <td><input name="Submit" type="submit" value="Submit" /></td> </tr> </table></form>