<h2>Contact<br /><br /></h2> <table border="0" cellspacing="0" cellpadding="0"> <tr> <td><span class="xbodytext">SIUE School of Nursing<br />Alumni Hall, Room 2117<br />Campus Box 1066<br />Edwardsville, IL&nbsp; 62026</span></td> <td><img height="1" width="25" alt="" src="../_global/img/spacer.gif" /></td> <td><span class="xbodytext">Main Line: 618-650-3956<br />FAX: 618.650-.3854<br />Toll Free: 800-234-4844<br />E-mail:&nbsp;<a href="mailto:nbieven@siue.edu">nbieven@siue.edu</a></span></td> </tr> </table> <p class="clrA"><span class="xsubheader">SON Information Request<br /></span> <span style="color:#FF0000">*</span><span class="clrA"><span class="xcaption"><span class="clrA">Required Information</span></span></span></p> <form name="mail" action="http://www.siue.edu/cgi-bin/FormMail.pl" method="post"> <p><input name="recipient" type="hidden" value="nbieven@siue.edu" /><input name="required" type="hidden" value="email,realname, address, city-state-zip, home phone, expected entry date" /><input name="redirect" type="hidden" value="http://www.siue.edu/nursing/thanks.shtml" /></p> <table border="0" cellpadding="5" cellspacing="0"> <tbody> <tr> <td><input name="realname" size="50" type="text" /><br /> <span style="color:#FF0000">*</span><span class="xbodytext">Name</span></td> </tr> <tr> <td><span class="xbodytext"><input name="address" size="50" type="text" /><br /> <span style="color:#FF0000">*</span>Address</span></td> </tr> <tr> <td><span class="xbodytext"><input name="city-state-zip" size="50" type="text" /><br /> <span style="color:#FF0000">*</span>City/State/Zip</span></td> </tr> <tr> <td><span class="xbodytext"><input name="county" size="50" type="text" /></span><br /> <span class="xbodytext">County</span></td> </tr> <tr> <td><span class="xbodytext"><input name="birthdate" size="50" type="text" id="birthdate" /></span><br /> <span class="xbodytext">Birth Date</span></td> </tr> <tr> <td><span class="xbodytext"><input name="gender" size="50" type="text" id="gender" /></span><br /> <span class="xbodytext">Gender</span></td> </tr> <tr> <td> <p class="xbodytext"><input name="home phone" size="50" type="text" /><br /> <span style="color:#FF0000">*</span>Home Phone</p> </td> </tr> <tr> <td><span class="xbodytext"><input name="work phone" size="50" type="text" /><br /> Work Phone</span></td> </tr> <tr> <td><span class="xbodytext"><input name="cell phone" size="50" type="text" /><br /> Cell Phone</span></td> </tr> <tr> <td><span class="xbodytext"><input name="hs_grad_date" size="50" type="text" id="hs_grad_date" /></span><br /> <span class="xbodytext">High School Graduation Date:&nbsp; 00/00/00</span></td> </tr> <tr> <td><span class="xbodytext"><input name="some_college" size="50" type="text" id="some_college" /></span><br /> <span class="xbodytext">Some College (Number of Hours)</span></td> </tr> <tr> <td><span class="xbodytext"><input name="college_grad_date" size="50" type="text" id="college_grad_date" /></span><br /> <span class="xbodytext">College Graduation Date:&nbsp; 00/00/00</span></td> </tr> <tr> <td><span class="xbodytext"><input name="degree_received" size="50" type="text" id="degree_received" /></span><br /> <span class="xbodytext">Degree Received</span></td> </tr> <tr> <td><span class="xbodytext"><input name="current_status" size="50" type="text" id="current_status" /></span><br /> <span class="xbodytext">Current Status/Occupation</span></td> </tr> <tr> <td><span class="xbodytext"><input name="expected entry date" size="50" type="text" /><br /> <span style="color:#FF0000">*</span>Expected Entry Date: 00/00/00</span></td> </tr> <tr> <td><span class="xbodytext"><input name="email" size="50" type="text" /><br /> <span style="color:#FF0000">*</span>E-mail Address</span></td> </tr> <tr> <td></td> </tr> <tr> <td> <span style="color:#FF0000">*</span><span class="xbodytext">Program of Interest</span> <br /> <br /> <table border="0" cellpadding="0" cellspacing="0"> <tbody> <tr> <td><input name="extras" type="checkbox" value="Undergraduate Program" />Undergraduate Program</td> <td><img height="1" width="25" alt="" src="index_files/spacer.gif" /></td> <td><input name="extras" type="checkbox" value="Registered Nurse Programs" />Registered Nurse Programs</td> </tr> <tr> <td><input name="extras" type="checkbox" value="Gerontological Nursing" />Gerontological Nursing</td> <td></td> <td><input name="extras" type="checkbox" value="Nursing Management" />Nursing Management</td> </tr> <tr> <td><input name="extras" type="checkbox" value="RN-BSN" />RN- BSN</td> <td></td> <td><input name="extras" type="checkbox" value="School Nurse Program" />School Nurse Program</td> </tr> <tr> <td><input name="extras" type="checkbox" value="Graduate Programs" />Graduate Programs</td> <td></td> <td><input name="extras" type="checkbox" value="Nurse Anesthesia" />Nurse Anesthesia</td> </tr> <tr> <td><input name="extras" type="checkbox" value="Public Health" />Public Health</td> <td></td> <td><input name="extras" type="checkbox" value="Nurse Practitioner" />Nurse Practitioner</td> </tr> <tr> <td><input name="extras" type="checkbox" value="Nurse Educator" />Nurse Educator</td> <td></td> <td><input name="extras" type="checkbox" value="Nurse Administrator" />Nurse Administrator</td> </tr> </tbody> </table> </td> </tr> <tr> <td></td> </tr> <tr> <td>Comments:<br /> <textarea name="comments" rows="5" cols="40" id="comments"></textarea></td> </tr> <tr> <td><input type="submit" value="Submit" /><br /> <br />&nbsp;</td> </tr> </tbody> </table> </form>