Saint Louis University School of Medicine

SAINT LOUIS UNIVERSITY SCHOOL OF MEDICINE ALUMNI MERIT AWARD NOMINATION FORM

Purpose: The President and administrative officers of Saint Louis University established the Alumni Merit Award to bring to the attention of the community and the nation in a dignified and dramatic way the end-product of the University's diverse, well-rounded educational program - namely its distinguished graduates.

Award Criteria: Any alumnus/a who exemplifies in his/her daily life the mission of Saint Louis University. These men and women shall have achieved outstanding success:

 in their civic leadership or social welfare activities (include offices held in Civic, Fraternal, Political or Labor Groups);  or in their professional life;  or in their intellectual or cultural pursuits (list memberships in Learned or Cultural Societies, articles published, books written, etc.);  or demonstrates continued interest and evidence of support toward the enhancement of Saint Louis University.

Note: Full-time Saint Louis University faculty are not eligible to receive the Alumni Merit Award. However, full-time faculty who are at the point of retirement or have already retired are eligible.

Nominating Candidates: Any person may recommend an alumnus/alumna for the Award. The nomination should contain a complete biographical sketch or profile of the person, together with the salient reasons why the nominee qualifies for this unique recognition.

Presentation of the Award: The recipient of the award must accept the award in person during the Medical Alumni Reunion Weekend held each year in October. ______

I (we) recommend the following Alumus/a to the Medical Alumni Association for consideration for the Alumni Merit Award:

Please print or type. Name: ______first name middle initial last name

Home Address: ______

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Business Address: ______

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Phone: (Home) ______(Business): ______

E-mail: ______11/ 2014 Education and degrees received from Saint Louis University:

School/College of ______Degree ______Year Rec'd ______

Date of Birth: ______Birthplace: ______

Family Information: (Name of spouse, years of marriage, names and ages of children) ______

Please briefly describe nominee's accomplishments demonstrating the criteria noted above and provide details of how the nominee exemplifies in his/her daily life the mission of Saint Louis University. ______

 Please include a complete biographical sketch, CV, resume, etc.  If available, please attach any letters of recommendation.

The above data are fair and accurate statements of facts concerning the above nominee.

Submitted by: ______first name middle last name Signature: ______

Address: ______

Phone: ______E-mail: ______

Date Submitted: ______

Nominations accepted via e-mail, fax or mail no later than April 15, 2015. Nominations must be mailed to the attention of Cheryl Byrd at: Saint Louis University, Medical Center Alumni Relations, 3545 Lafayette Avenue, Room 609, St. Louis, MO 63104. Nominations also accepted via e-mail to [email protected] or by fax to 314-977-7880 11/ 2014