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.

* 1. First Name

* 2. Last Name

* 3. Affiliated College/University

* 4. College/University City

* 5. College/University State

* 6. Please choose one of the following:

* 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.

* 8. Email

* 9. Telephone

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

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