HALL OF FAME

NOMINATION FORM

DEADLINE: FEBRUARY 1, 2007

TODAY’S DATE: _______________

INFORMATION ABOUT THE NOMINATOR

Name: _______________________________________________________

Address: ____________________________________________________________________________________________________________________________

Telephone: ______________________________________________________________

Relationship to Nominee: ___________________

INFORMATION ABOUT THE NOMINEE

Name: ________________________________________________________________

Name at graduation (birth name, etc.): ___________________________________

Address: ___________________________________________________

List the nominee’s significant career and professional accomplishments. Please include evidence including dates to document this nomination.

Describe the nominee’s contributions to society. Evidence to document this nomination should be attached.

List any peers and/or affiliates of the nominee whom the committee may contact to provide further information (name, address and telephone number if available).

Supply other information that you feel will support this nomination. You may use additional sheet of paper if necessary.

Feel free to take additional paper to complete the above information.

DEADLINE: FEBRUARY 1, 2007

I/We agree that all information provided can or may be used for purposes of evaluation and may be at some time publically shared in conjunction with the Hall of Fame program.