Address:

City:

State: 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: 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: