Saint LouisUniversity

Institute of Technology Merit Award

Nomination Form

I (we) recommend to the Alumni Association the following graduate to receive the Institute of Technology Alumni Merit Award.

NAME______

(title)(first name)(middle)(last)

DATE OF BIRTH______BIRTHPLACE______

CURRENT HOME ADDRESS______

______

CURRENT BUSINESS ADDRESS______

______

PHONE:HOME (___)______Email ______

BUS (___)______Fax ______

PRESENT OCCUPATION______

EDUCATION AND DEGREES RECEIVED FROM SAINT LOUISUNIVERSITY, INSTITUTE OF TECHNOLOGY:

School/College of ______Degree______Year______

School/College of ______Degree______Year______

School/College of ______Degree______Year______

EDUCATION AND DEGREES RECEIVED FROM OTHER UNIVERSITIES:

School/College of ______Degree______Year______

School/College of ______Degree______Year______

School/College of ______Degree______Year______

IF MARRIED:

1) Name of Spouse ______

2) Date of Marriage ______

3) Names and ages of children ______

______

4) Names of grandchildren ______

______

Please provide details of how the nominee exemplifies in his/her daily life the mission of Saint LouisUniversity.

1) LEADERSHIP IN CIVIC, SOCIAL, WELFARE ACTIVITES (include offices held in civic, fraternal, political, labor, or community groups)

______

______

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2) VOCATIONAL EVIDENCE (accomplishments in business or professional life and/or the advancement of engineering, technology or research efforts)

______

______

______

______

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3) INTELLECTUAL OR CULTURAL PURSUITS (list memberships in learned or cultural societies, articles published, books written, etc.)

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4) PERSONAL, HOME AND FAMILY LIFE (include service in parish, church synagogue or religious societies)

______

______

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______

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5) OTHER EVIDENCE OF OUTSTANDING CONTRIBUTIONS(list service to the Institute of Technology at Saint LouisUniversity and/or other engineering and scientific educational institutions, military service record or any other not included above)

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If available, please attach a current resume.

RECOMMENDED BY:

(One signature is necessary; more may be used)

The above data are fair and accurate statements of fact concerning the above nominee.

SIGNED:______

(name)

______

(address)

______

SIGNED:______

(name)

______

(address)

______

Date Submitted:______

Nominations should be sent to:Saint LouisUniversity

Office of Alumni Relations

221 N. Grand Boulevard

DuBourg Hall, room 341B

St. Louis, MO 63103

For questions concerning the nomination, call 314-977-2250.

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