Western Illinois University: Macomb Campus

First Name*

Middle Name/Initial

Last Name*

Maiden Name

Graduation Year (earliest degree)*

Street Address

City*

State*

Zip

Is this a new address?

Yes No

Home Phone

Cell Phone

Would you like to receive text messages from the University?

Yes No

Do you have a second Home Address?

Yes No

Second Street Address

Second City

Second State

Second Zip

Personal E-mail Address*

Web Page Address:

Title/Position*

Employer*

Employer's Address

Your Business Phone

Your Business Email

Marital Status Select Status... Single Married Divorced Widowed Domestic Partner

Is your spouse/domestic partner a WIU graduate?

Yes No

If yes, which year did he/she graduate?

Full Name:

Your Children's Names and Birthdates:

Hobbies

What was your favorite college hangout?

What impact has your education from Western Had on your life?

Western Memories

Which faculty/staff member influenced you the most and how?

Additional information you would like printed in the "Memory Booklet"