Full name of student:

Address: (local or campus)

City:

Phone:

E-mail:

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

College GPA: (required)

Student ID number: (required)

Number of semester hours completed

Graduation Date: (required)
Nominees will have graduated in summer (August 2010), fall (December 2010) or are candidates for graduation in spring 2011.

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

Leadership Activities
May include UIC student organizations, volunteer services or campus departments; paid positions are eligible.

Nominee Endorsement
Please describe in detail why you believe this student should receive the Student Leadership Award. Please refer to the roles in the activities listed above.

Information About The Nominator

Nominated by:

Your address:

Phone number:

FAX number:

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