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, faculty and organizations interested in the surplus lines industry.

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* 1. First Name

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* 2. Last Name

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* 3. Affiliated College/University/Organization

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* 4. City of your College/University/Organization

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* 6. Please choose one of the following:

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* 7. If a student, please graduation month and year that best fits  your academic plans, so we may anticipate when you will no longer wish to receive student emails.

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* 8. Email

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* 9. Telephone

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

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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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