Provide some basic contact information below to be added to WSIA's contact list for internship updates, symposium dates, and other items items pertaining to students and educators interested in the surplus lines industry.

First Name

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* 1. First Name

Last Name

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* 2. Last Name

Affiliated College/University

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* 3. Affiliated College/University

College/University City

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* 4. College/University City

College/University State

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* 5. College/University State

Please choose one of the following:

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* 6. Please choose one of the following:

If a student, please indicate your anticipated graduation semester and year so we may anticipate when you will no longer wish to receive student emails.

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* 7. If a student, please indicate your anticipated graduation semester and year so we may anticipate when you will no longer wish to receive student emails.

Email

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* 8. Email

Telephone

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* 9. Telephone

Are you a member of Gamma Iota Sigma?

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* 10. Are you a member of Gamma Iota Sigma?

If you are a GIS officer for your school's chapter, please include your title below.

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* 11. If you are a GIS officer for your school's chapter, please include your title below.

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