| Nominee: | |
| Class: | |
| Address: | |
| City: | |
| State: |
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| Zip: | |
| Daytime telephone: | |
| Evening Telephone: | |
| Email: | |
| Norwich degree and major: | |
| Corps or civilian? | |
| Sports, activities, clubs at Norwich: | |
| Other degrees/universities/specialties: | |
| Spouse (include maiden name): | |
| NU/VC? | |
| Children (names and ages): | |
| Any children attend NU/VC? | |
| Current employer & job title (if retired, previous profession): | |
| Nominated by: |
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| Class: | |
| Date (mmddyy): | |
| Please give a brief description of the nominee's alumni or other volunteer involvement: | |
| Describe the nominee's professional/military/civic career highlights/experience: | |
| : |
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