NOMINEE INFORMATION

Please complete the following form about the individual you seek to nominate.

Last Name:

First Name:

Middle Initial:

Maiden Name (if applicable):

Address

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Phone Number

###

###

####

Email Address

Graduation Year:

NOMINATOR INFORMATION

Please provide your contact information so we may contact you with additional questions about your nominee.

Last Name:

First Name:

Middle Initial:

Address

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Phone Number

###

###

####

Email Address

Graduation Year:

BUSINESS/PROFESSIONAL/UNIVERSITY SERVICE & ACTIVITY INFORMATION

Please provide a brief explanation of the qualifications of this nominee for Alumni Board membership. Please use your own words to list relevant accomplishments or other recognition.