<script type="text/javascript" language="JavaScript"><!--function init(){ var formName = "AlumniAmbassadorStudentReferral"; var form = eval("document." + formName); form.reset(); } //End of initfunction boxFocused(boxName){ var formName = "AlumniAmbassadorStudentReferral"; var box = eval("document." + formName + "." + boxName); box.select(); box.focus();}// End of function boxFocusedfunction focusFirstMissingField(boxName, boxValue){ var formName = "AlumniAmbassadorStudentReferral"; var box = eval("document." + formName + "." + boxName); // alert(boxValue); box.value = boxValue; boxFocused(boxName);}// End of focusFirstMissingField function checkSpace(content){ var correct = true; var contentName = eval("document.AlumniAmbassadorStudentReferral." + content); if(contentName.value == ""){ correct = false; } return correct; } // End of checkSpace function validate(){ var correct = true; var errorInfo = "The following field(s) is/are missing:"; var formName = "AlumniAmbassadorStudentReferral"; var form = eval("document." + formName); if((!checkSpace("a_01_student_first_name")) || (form.a_01_student_first_name.value == "First Name")){ errorInfo += "\n- First name"; } if((!checkSpace("a_02_student_last_name")) || (form.a_02_student_last_name.value == "Last Name")){ errorInfo += "\n- Last name"; } if((!checkSpace("a_04_student_address")) || (form.a_03_student_address.value == "Address")){ errorInfo += "\n- Address"; } if((!checkSpace("a_05_student_city")) || (form.a_05_student_city.value == "City")){ errorInfo += "\n- City"; } if((!checkSpace("a_06_student_state")) || (form.a_06_student_state.value == "State")){ errorInfo += "\n- State"; } if((!checkSpace("a_07_student_Zip")) || (form.a_07_student_Zip.value == "ZIP")){ errorInfo += "\n- ZIP Code"; } if((!checkSpace("c_01_alum_name")) || (form.c_01_alum_name.value == "Referring Alum's Name")){ errorInfo += "\n- Referring Alum's Name"; } if((!checkSpace("c_02_alum_phone")) || (form.c_02_alum_phone.value == "Referring Alum's Phone")){ errorInfo += "\n- Referring Alum's Phone"; } if (errorInfo != "The following field(s) is/are missing:"){ correct = false; } if(!correct){ alert(errorInfo); } return correct; } // End of validate--></script><span class="header">Alumni Ambassadors Prospective Student Referral Form</span> <form onsubmit="return validate();" name="AlumniAmbassadorStudentReferral" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post"> <input name="recipient" type="hidden" value="ddennis@siue.edu" /><input name="email" type="hidden" value="ddennis@siue.edu" /><input name="subject" type="hidden" value="Alumni Ambassador Student Referral" /><input name="redirect" type="hidden" value="http://www.admissions.siue.edu/AlumniAmbassadorProgram/referralresponse.htm" /> <p><input name="a_01_Student_First_Name" maxlength="35" size="48" value="Prospective Student's First Name" onfocus="boxFocused(this.name);" id="a_01_student_first_name" align="middle" /><span class="style1">*</span></p> <p><input name="a_02_Student_Last_Name" maxlength="35" size="48" value="Last Name" onfocus="boxFocused(this.name);" id="a_02_student_last_name" align="middle" /><span class="style1">*</span></p> <p><input name="a_04_Student_Address" maxlength="45" size="48" value="Address" onfocus="boxFocused(this.name);" id="a_04_student_address" /><span class="style1">*</span></p> <p><input name="a_05_Student_City" maxlength="15" size="15" value="City" onfocus="boxFocused(this.name);" id="a_05_student_city" />&nbsp;<span class="style1">*</span> &nbsp; <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> &nbsp;<span class="style1">*</span>&nbsp; <input name="a_07_Student_Zip" maxlength="5" size="5" value="ZIP" onfocus="boxFocused(this.name);" id="a_07_student_zip" /> <span class="style1">*</span></p> <p><input name="a_08_Student_SSN" maxlength="42" size="48" value="Social Security Number (optional)" onfocus="boxFocused(this.name);" id="a_08_student_ssn" /></p> <p><input name="a_09_Student_DOB" maxlength="42" size="48" value="Date of Birth (mm/dd/yyyy)" onfocus="boxFocused(this.name);" id="a_09_student_dob" /></p> <p><input name="a_10_Student_Day_Phone" maxlength="42" size="48" value="Day Phone" onfocus="boxFocused(this.name);" id="a_10_student_day_phone" /></p> <p><input name="a_11_Student_Evening_Phone" maxlength="42" size="48" value="Evening Phone" onfocus="boxFocused(this.name);" id="a_11_student_evening_phone" /></p> <p><input name="a_12_Student_email" maxlength="42" size="48" value="E-mail Address" onfocus="boxFocused(this.name);" id="a_12_student_email" /></p> <p><input name="a_13_Student_Last_HS_or_College" maxlength="42" size="48" value="High School or College Last Attended" onfocus="boxFocused(this.name);" id="a_13_student_last_hs_or_college" /></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>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <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></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></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></p> <p><strong>Please send the student:</strong> (check all that apply)</p> <p><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><input name="b_02_housing" type="checkbox" value="Housing Information" id="b_02" />University Housing Information</p> <p><input name="b_03_scholarship_app" type="checkbox" value="Scholarship Application" id="b_03" />Scholarship Application</p> <p><input name="b_04_army_rotc_info" type="checkbox" value="Army ROTC" id="b_04" />Army ROTC Information</p> <p><input name="b_05_air_force_rotc_info" type="checkbox" value="Air Force ROTC" id="b_05" />Air Force ROTC Information</p> <p><input name="b_06_transfer_info" type="checkbox" value="Transfer Information" id="b_06" />Transfer Information</p> <p><input name="b_07_visit_information" type="checkbox" value="Visit Information" id="a_42" />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" maxlength="42" size="48" value="Referring Alum's Name" onfocus="boxFocused(this.name);" id="c_01_alum_name" /></p> <p><input name="c_02_alum_phone" maxlength="42" size="48" value="Referring Alum's Phone" onfocus="boxFocused(this.name);" id="c_02_alum_phone" /></p> <p><input name="c_03_alum_email" maxlength="42" size="48" value="Referring Alum's E-mail" onfocus="boxFocused(this.name);" id="c_03_alum_email" /></p> <p><input name="Submit" type="submit" value="Refer Student" /><br /> <span class="rtbodytext">(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>