Fields with asterisks (*) are required.

Nominee

First name *

Last name *

Email *

Graduation Year *

Specialty *

Address

Home Phone

Office Phone

Nominator

First Name *

Last Name *

Email *

Graduation Year *

Specialty *

Address

Home Phone

Office Phone

Select Nominee Award *

Please Select Distinguished Alumni Award Lawrence M. Weiner Award Recent Alumni Award

Submit cover letter explaining why you believe this person should be considered *

Candidate’s current CV *

Please list any other relevant information that the committee may find helpful in reaching its decision, as they receive several qualified applicants each year