Inquiry Form - Extended Campus - Off Campus Locations Only

First Name

Last Name

Preferred Email Address

Birthdate

May we send you text messages?

Cell Phone

Phone

When do you plan to begin attending SIU?

Prospective Student Level

I am interested in SIU as a:

Location you are interested in taking courses:

Site you are interested in taking courses:

Primary Academic Interest

Would you like to receive mail from SIU?

Country

Street

City

Region

Postal Code

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