| Fraternity or Sorority Name: * |
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| Fraternity or Sorority Location (City): * |
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| First Name: * |
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| Last Name: * |
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| Home Address Street 1: * |
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| Home Address Street 2: |
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| City: * |
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| Zip Code: * |
(5 digits) |
| State: * |
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| Home Phone: * |
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| Cell Phone: * |
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| School Issued Email: * |
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| Alternate Email:: * |
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| School Issued ID#: * |
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| Room Number: * |
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| Computer Make / Model: * |
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| Desktop or Laptop: * |
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| Operating System: * |
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| Firewall Software (if any): |
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| Anti Virus Software (if any): |
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Wireless Physical Address: *
(This is the MOST important part of the form. If you dont know how to find this address, please call the HELP DESK 309-673-1432) |
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