<script type="text/JavaScript" src="http://www.siue.edu/prospectivestudents/prospective_3col_js.js" language="JavaScript"><!----></script>
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<h2>SIUE Student Referral Form</h2>
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<form onsubmit="return checkFieldsStudentReferral()" name="StudentReferralForm" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post" id="StudentReferralForm">
Please use this form to let us know about a student you think might be a good fit for study at SIUE. We will then contact the student to inform her or him of the opportunities available at SIUE. Thank you for your help in bringing students to SIUE.<input name="recipient" type="hidden" value="ebthomp@siue.edu" /><input name="email" type="hidden" value="ebthomp@siue.edu" /><input name="subject" type="hidden" value="Student Referral Form" /><input name="redirect" type="hidden" value="http://www.siue.edu/prospectivestudents/Student_Referral_Thanks.shtml" />
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<div align="left"><strong> <br />Student Information</strong></div>
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<p><input name="aa_Student_First_Name" size="41" maxlength="41" type="text" value=" Student First Name" onfocus="this.select()" /> <input name="aa_Student_Middle_Name" size="4" maxlength="4" type="text" value=" MI" onfocus="this.select()" /></p>
<p><input name="ab_Student_Last_Name" size="50" maxlength="40" type="text" value=" Student Last Name" onfocus="this.select()" /></p>
<p><input name="ac_Student_Address" size="50" maxlength="50" type="text" value=" Student Address" onfocus="this.select()" /></p>
<p><input name="ac_Student_Address2" size="50" maxlength="50" type="text" value=" Student Address 2" onfocus="this.select()" /></p>
<p><input name="ad_Student_City" size="50" maxlength="50" type="text" value=" Student City" onfocus="this.select()" /></p>
<p><select name="ae_Student_State"><option>Student State</option> <option value="Illinois ">Illinois</option> <option value="Missouri ">Missouri</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="New Hampshire ">New Hampshire</option> <option value="New Jersey ">New Jersey</option> <option value="New Mexico ">New Mexico</option> <option value="New York ">New York</option> <option value="North Carolina ">North Carolina</option> <option value="North Dakota ">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="Rhode Island ">Rhode Island</option> <option value="South Carolina ">South Carolina</option> <option value="South Dakota ">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="Washington, D.C. ">Washington, D.C.</option> <option value="West Virginia ">West Virginia</option> <option value="Wisconsin ">Wisconsin</option> <option value="Other">Other</option> </select> <input name="af_Student_ZIP" size="27" maxlength="27" type="text" value=" Student ZIP Code" /></p>
<p><input name="ag_Student_Birth_Date" size="50" maxlength="50" type="text" value=" Student Birth Date (mm/dd/yyyy) - optional" onfocus="this.select()" id="ac_Birth_Date" /></p>
<p><input name="ah_School_Attended" size="50" maxlength="50" type="text" value=" School Most Recently Attended" onfocus="this.select()" /></p>
<p><select name="ai_School_Type"><option>Type of School</option> <option>High School</option> <option>College</option> <option>Community College</option> <option>Other</option> </select></p>
<p><input name="aj_Student_Graduation_Date" size="50" maxlength="50" type="text" value=" Graduation Date (actual or expected)" onfocus="this.select()" /></p>
<p><select name="ak_Student_Gender"><option>Student Gender</option> <option value="Female">Female</option> <option value="Male">Male</option> </select></p>
<p><select name="al_Student_Ethnicity"><option>Student Ethnicity (optional)</option> <option value="White, Non-Hispanic">White, Non-Hispanic</option> <option value="Black, Non-Hispanic">Black, Non-Hispanic</option> <option value="Hispanic">Hispanic</option> <option value="Asian/Pacific Islander">Asian/Pacific Islander</option> <option value="American Indian/Alaskan Native">American Indian/Alaskan Native</option> <option value="Other">Other</option> </select></p>
<p><select name="am_Entry_Term"><option>Student's SIUE Entry Term</option> <option value="Spring '10">Spring '10</option> <option value="Summer '10">Summer '10</option> <option value="Fall '10">Fall '10</option> <option value="Spring '11">Spring '11</option> <option value="Summer '11">Summer '11</option> <option value="Fall '11">Fall '11</option> <option value="Spring '12">Spring '12</option> <option value="Summer '12">Summer '12</option> <option value="Fall '12">Fall '12</option> <option value="Other">Other</option> <option value="Don't Know">Don't Know</option> </select></p>
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<p><strong> <br />Referrer Information</strong></p>
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<p><input name="ba_Referrer_First_Name" size="41" maxlength="31" type="text" value=" Referrer First Name" onfocus="this.select()" /> <input name="ba_Rereffer_Middle_Name" size="4" maxlength="4" type="text" value=" MI" onfocus="this.select()" /></p>
<p><input name="bb_Referrer_Last_Name" size="50" maxlength="30" type="text" value=" Referrer Last Name" onfocus="this.select()" /></p>
<p><input name="bc_Referrer_Email" size="50" maxlength="50" type="text" value=" Referrer E-mail" onfocus="this.select()" /></p>
<p><input name="bd_Referrer_Phone" size="50" maxlength="50" type="text" value=" Referrer Phone (555-555-5555)" onfocus="this.select()" /></p>
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<div align="left"><br /> </div>
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<td align="left"><input name="Submit" type="submit" value="Submit" /> (Please click only once and wait for the response page.)</td>
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<p><input name="Reset" type="reset" value="Reset " /></p>
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