Alumni Award Nomination Form

Printable PDF Form

Nominator (Responses will not be saved prior to submission)

First Name

Last Name

Street Address

City

State/Province

Zip/Postal Code

Telephone

E-mail

Date of Nomination

Recipients are selected based on outstanding service, excellence in teaching, research, and practice, and for notable contributions in clinical, diagnostic, military, public health, regulatory, or other practice service.

Nominee

Please provide as much detailed information on the nominee as possible below.

First Name

Last Name

Street Address

City

State/Province

Zip/Postal Code

Telephone

E-mail

Year of Graduation

Employment History (please send nominee's current curriculum vitae to awheatley@wsu.edu)

Personal History: Spouse's name (living or deceased?), children's names, hobbies

Membership in community organizations. (Name of organizations and history of involvement.)

Membership in professional organizations. (Name of organizations and history of involvement.)

How long have you known the nominee?

What is your relationship with the nominee?

How has this nominee changed your life or the lives of others? (give specific example)

What challenges has this nominee faced and overcome that have inspired others? (give specific example)

What are some of the nominee's special goals?

What are the nominee's priorities in life?

Name five (5) outstanding contributions to practice or teaching and research. For example: Awards received; special recognition by peer groups (professional or non-professional); demonstration of commitment to continuing education

How have these contributions made a change for the better? (give specific example)

Other information you would like to share about the nominee?

Supporting File(s) Upload

Upload any additional materials you feel relevant to this nomination. File types allowed: jpg, jpeg, png, gif, bmp, pdf, doc, docx, ppt, pptx, ppsx, xls, and xlsx.

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