Southern Illinois University School of Medicine Office of Alumni Affairs

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Class Agent Form

Thank you for your interest in becoming a class agent. The following form can be used to contact us. Of course this information is kept confidential.

 

Name  
Email  
Mailing Address  
City State Zip  
Home Phone
area code, prefix, number
 
Work Phone
area code, prefix, number
 
FAX Number
area code, prefix, number
 
I will not be able to serve as Class Agent, but recommend the following person(s).
   
         
 
If you would rather send your information to us U.S. mail or fax please use this pdf file.
Phone 217-545-7800
P.O. Box 19650
Springfield, IL 62794-9650
The mission of Southern Illinois University School of Medicine is to assist the people of central and southern Illinois in meeting their health care needs through education, patient care, research and service to the community.

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