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<B><FONT SIZE=+2 <FONT color=ff0099>HMD Mailing List</FONT></B><P>
<B>Join the HMD mailing list! Simply fill out this form to be added to our mailing list and receive information about all of our amazing programs!</B>
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<FORM method="POST" action="/cgi-bin/mailform?hillelmail">
Name
<BR><input type="text" name="name" size=60><P>
Street
<BR><input type="text" name="street" size=60><P>
Apartment #
<BR><input type="text" name="aptno" size=60><P>
City, State and ZIP
<BR><input type="text" name="city" size=60><P>
Home phone
<BR><input type="text" name="homephone" size=60><P>
Work phone
<BR><input type="text" name="workphone" size=60><P>
E-mail
<BR><input type="text" name="email" size=60><P>
Date of Birth
<BR><input type="text" name="dateofbirth" size=60><P>
Occupation
<BR><input type="text" name="occupation" size=60><P>
University attended/attending
<BR><input type="text" name="university" size=60><P>
Major
<BR><input type="text" name="major" size=60><P>
Year of Graduation/anticipated graduation
<BR><input type="text" name="yeargraduate" size=60><P>
Are you currently enrolled
<BR><input type="radio" name="current" value="currently enrolled: Yes"> Yes<BR>
<input type="radio" name="current" value="currently enrolled: NO"> No
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Interests (please mark all that apply)
<BR><input type="radio" name="interest1" value="Social">Social
<BR><input type="radio" name="interest2" value="Sports">Sports
<BR><input type="radio" name="interest3" value="Speakers">Speakers
<BR><input type="radio" name="interest4" value="Israel">Israel
<BR><input type="radio" name="interest5" value="Jewish Awareness">Jewish Awareness
<BR><input type="radio" name="interest6" value="On campus programs">On campus programs (specify campus) <input type="text" name="specify" size=30>
<BR><input type="radio" name="interest7" value="United Jewish Appeal">United Jewish Appeal
<BR><input type="radio" name="interest8" value="Shabbat Dinners">Shabbat Dinners
<BR><input type="radio" name="interest9" value="Community Service">Community Service<bR>
Other <input type="text" name="otherinterest" size=60>
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Comments, suggestions, or names/addresses of friends:<BR>
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<INPUT Type="submit" value="Send To HILLEL"> <INPUT Type="reset" value="Redo"><P>
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<FONT SIZE=+2 color=#FF0099>Thanks!</FONT>
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<TD>© 1999 Hillel of Metro Detroit<BR>
667 Grosberg Center<BR>
Wayne State University<BR>
Detroit, Michigan 48202<P>
phone: 313-577-3459<BR>
hotline:313-577-8888<BR>
fax: 313-577-3461<BR>
email: <a href=mailto:hillel@wayne.edu>hillel@wayne.edu</a><p>
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