Nomination Form

Nominator's Information

Personal Information

Street

City

State

Zip

Preferred Email ■

Preferred Daytime Phone Number

Please include area code.

Alternative Phone Number

Please include area code.

Employer Information

Place of Employment

Street

City

State

Zip

Nominee's Information

Personal Information

Name

Please include first and last name.

Mailing Address

Street

City

State

Zip

Preferred Email ■

Preferred Daytime Phone Number ■

Please include area code.

Degree(s) Earned

List degree(s) and year(s) the nominee received from the University of Wisconsin Oshkosh

Other Degree(s)

List any degree(s) awarded by non-UW Oshkosh educational institutions.

Employer Information

Place of Employment

Title

Street

City

State

Zip

Business Email

Business Phone Number

Please include area code.