Southern Illinois University School of Medicine

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.