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

Other Information for the Alumni Magazine
and additional comments: