College of Liberal Arts and Sciences

Distinguished Alumni-in-Residence

October 27 and 28, 2011

This form is for the nomination of honorees for the 2011 CLAS Distinguished Alumni-in-Residence Celebration. Each department's contact for coordination of their honoree should fill out each section as completely as possible. After completing the form, the department contact will receive a copy by e-mail of the data that was input. We encourage you to have your honoree review the data entered for accuracy and to provide any recent updates. The form must be submitted by Friday, September 9, 2011. Biographies may be edited as late as Friday, October 7, 2011. Please contact Keesha Hardiman at (616) 331-2495 or hardimak@gvsu.edu with any questions. Thank you.

Note: * indicates a required field.

Department Contact Information
First Name:*	Last Name:*
Department: *	Telephone Ext.: *	(Example 1-2495)
E-mail Address: *
Will your honoree be co-sponsored by another department? *
If you responded "Yes" to the question above, with which department will you co-sponsor?

Honoree Information
First Name: * Middle Name: Last Name: *
Preferred Name:	Preferred Title:	(Example: Dr.)
Place of Employment: *
Job Title: *

Honoree Contact Information
Street Address: *		Apt #.:
City: *
State: *		Zip Code: *
E-mail Address: *
Preferred Phone #:	(Example: 616-555-1212)
Type of Phone:

Educational Information
GVSU Degree(s): *
Degree #1: *		Major/Emphasis: *
Other Degree:		Minor (Optional):
		Year Obtained: *
Degree #2:		Major/Emphasis:
Other Degree:		Minor (Optional):
		Year Obtained:
Degree(s) from Other Institutions:
Degree:		Major/Emphasis:
Other Degree:		Year Obtained:
Institution: