Western Illinois University: Macomb Campus

First Name*

Middle Name/Initial

Last Name*

Maiden Name

Did you receive a degree from WIU?*

Yes No

If yes, what was your 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

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:

Title/Position:

Employer:

Employer's Address:

Business Phone:

Business Email:

Your Children's Names and Birthdates:

Would you like us to publish your e-mail address in Western News?
Personal Business None

May we include occupational information in the Western News?
Yes No

Other Information for Western News
and additional comments: