Nomination a Distinguished Alumnus

Please fill out tohe form below and enter the following information about the nominee. Alternatively you can download the form, print it, and mail it to:

Office of Advancement
202 Law Building
504 E. Pennsylvania Avenue
Champaign, IL 61820

*Required Fields

*First Name:	Please enter the nominee's name.
*Last Name:	Please enter the nominee's name.
*Home Address:	Please enter the nominee's home address.
*Home City:	Please enter the nominee's home city.
*Home State:	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Home Zip:	Please enter the nominee's home zip code.
*Home Phone:	Please enter the nominee's home phone.
*Home E-mail:	Please enter the nominee's home e-mail.
*Business Address:	Please enter the nominee's business address.
*Business City:	Please enter the nominee's business city.
*Business State:	Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
*Business Zip:
*Business Phone:
*Business Email:
*UIUC Degrees: (include dates conferred)
Other Degrees: (include dates conferred & university name)
*State of why the nominee deserves this award:
*Career since leaving the University:
*Special Recognitions, Honors, and Awards:
*Publications and Patents:
*Civic Activites and Philanthropic Endeavors:
Any other information you would like to include: