Outstanding Alumni Nomination

Thank you for taking the time to make a nomination for the WSU Boonshoft School of Medicine Outstanding Alumni Award. Please fill out as much information as you can. Nominations are due by November 1st of each year.


Nominee

Graduation Year

Name

Address

City

State

Zip Code

Phone
(please include area code)

Email Address


Supporting Evidence

Volunteer Work and
University Service

Professional Achievements
and Affiliations

Publications, Distinctions, Honors and Awards

Education

If possible, please send additional supporting documentation such as biographical sketch, curriculum vita, or resume (email, mailing address, and fax number are listed below.)


Nominator

If you're nominating yourself, please leave this section blank.

Graduation Year

Name

Address

City

State

Zip Code

Phone
(please include area code)

Email Address

You may also fill out this form, print it and send it along with supporting documentation to:

Office of Advancement
Boonnshoft School of Medicine
3640 Colonel Glenn Highway
Dayton, OH 45435
(937) 775-2972
FAX: (937) 775-3254