Personal Information

First Name*

Middle Name

Last Name*

Last Name while at IU

E-mail*
Your e-mail address will not be shared with outside parties and will only be used to contact you about IU-related matters.

Home Phone
( ) -

Work Phone
( ) -

Cell Phone
( ) -

How would you like to be contacted?

E-mail

Home Phone/Mailings

Work Phone/Mailings

Cell Phone

Home

Your home address is needed to match you with your local legislative districts.

Street Address*

City*

State*
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip*

Business or School Address

Street Address

City

State
Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip

What is your relationship to Indiana University?

Alumnus/Alumna or Friend

Graduate

Attended IU but have not graduated

Member of the IU Alumni Association

Friend of IU but never attended

If you attended IU, what years did you attend?
-

Faculty or Staff

Faculty

Staff

Retired Faculty

Retired Staff

Current Student

Undergraduate

Graduate

Expected Graduation Date

Month
Select January February March April May June July August September October November December

Year
Select 2008 2009 2010 2011 2012 2013

How would you like to help?

Be a Community Captain

Be a Student Captain

Attend meetings

Make phone calls

Recruit fellow alumni, students, and friends

Please list any state legislators that you know: