Please return this Nomination Form to:

Nominee:_____________________________________________________________________ Class:________

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 (including maiden name):_______________________________________________NU/VC?________

Children (names & ages):____________________________________________________________________

Any children attend/graduate from NU/VC?____________________________________________________________________

Current employer & job title (if retired, previous profession):_____________ ___________________________________

Nominated by:_____________________________________________Class:_______Date:__________________

Please give a brief description of the nominee's alumni or other volunteer involvement:

____________________________________________________________________________________

____________________________________________________________________________________

Describe the nominee's professional/military/civil career highlights/experience: (if necessary use reverse side):

____________________________________________________________________________________

____________________________________________________________________________________