Nominee name:

Nominee Address: 

Telephone: 

E-mail: 

Fax Number: 

Nominee’s hometown:      

Nominee’s hometown and current local newspapers: 

Year(s) graduated or attended IUP: 

Degree(s) from IUP:  Bachelor's  Master's Doctorate

Education other than IUP:
 

Place of Employment:  

Title: 

Business address: 

Telephone: 

E-mail: 

Fax Number: 

List memberships or directorships: 

List current and past IUP activities/involvement: 

IUP awards/recognition:     

Business/professional honors, awards, or achievements:     

  

Community service, honors, and awards (include civic, religious, youth and philanthropic activities): 

Information about nominee’s family (number of children, name(s) and age(s) of children, spouse’s name, spouse’s business/profession, etc.): 

Please list additional information concerning the nominee which you feel may be helpful to the Alumni Awards Committee in making its selection:

Nominator’s statement regarding why the nominee should be selected as a distinguished alumna/alumnus: 

Nominator's Name:  

Address:    

Telephone: 

E-Mail Address: