Full name:

Address: (local or campus)

City:

Phone:

E-mail:

Cumulative College GPA (Required)

College
Select one: Applied Health Sciences Architecture and the Arts Business Administration College of Medicine Ð Chicago College of Medicine Ð Peoria College of Medicine Ð Rockford College of Medicine Ð Urbana Dentistry Education Engineering Liberal Arts and Sciences Nursing Pharmacy Public Health Social Work Urban Planning and Public Affairs

Student ID Number (Required)

Graduation Date

Number of Semester Hours Completed (Required)
(Nominees must have at least 72 credit hours completed by the end of spring 2012.)

If you are nominating more than one student, please rank this nominee here:
Rank of

Leadership Activities

(Nominee must be associated with at least three diverse REGISTERED UIC student organizations, with a key leadership role in at least one of the three.) ACCETABLE ORGANIZATIONS

.

Nominee Endorsement
Please describe in detail the student's involvement in the student organizations listed above, and how his or her experiences in them have made a positive impact on the UIC Community.

Information About The Nominator

Nominated by:

Your address:

Phone number:

FAX number:

Your e-mail address (Necessary in order to process this form.):