Please enter your name, student ID, and the other information in the boxes provided. Then press the "Submit" botton.

RE 472 Student Information Form

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This information is requested in order to foster better communication with the instructor.  The information will only be used by me and will not be shared with anyone else.  There may be times during the semester when I need to contact you.  While this information is supposed to be already available, I find that the university information is sometimes out of date. 

Login ID 
(This can be any name you wish to use.  It is used to access the testing website.)

Last Name 

First Name

Preferred Email Address 
(This is where you wish to receive email.)

Password
(Choose at least a four number or letter password that you can remember!  You may use more than four numbers or letters up to a maximum of eight.)

Role in Course

Student ID 

Middle Name* 

Course Type 

Department Offered 

Institution

Local Address 1 

Local Address 2 

City 

State 

Zip code 

Country* 

Business Phone* 

Home Phone*  

Business Fax* 

Cell Phone*   

Web Page* 

*Optional

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Send mail to Dr. Jerry Belloit with questions or comments about this web site.
Copyright 2006  Dr. Jerry D. Belloit