Phillips County Alumni

Phillip County Alumni Information Submission Form
We appreciate you taking the time to submit your information for our records.
If you have any questions about the privacy of your information, please contact pced@pctelcom.coop

Last Name:	*
First Name:	*
Maiden Name:
Mailing Address:	*
City:	*
State:	*
Zip:	*
Email Address:	*
Work Phone:
Home Phone:
Cell Phone:
Year of High School Graduation:	*
High School Graduated From:	*
Level of Education and/or Degree:
Occupation:
Spouse's Occupation (if married):

Number of Dependent Children:
0-5 6-12 13-18
Interest in relocating family to Phillips County:
Strong Interest Some Interest No Interest
Interest in starting business in Phillips County:
Strong Interest Some Interest No Interest
Interest in being contacted by any business in Phillips County about:
Product Service Possible Job
Comments:


* Required
Note: If you move, please return to this page and submit the survey again. Our database will update and email us with your most current information.