Nomination Form – Part A
Chancellor’s Award for Student Excellence 2015
The Chancellor's Award for Student Excellence acknowledges students who have received recognition for student excellence. We are seeking nominations of students who have best demonstrated, and been recognized for, the integration of academic excellence with other aspects of their lives, which may include leadership, campus involvement, community service, arts (creative or performing), athletics and/or career achievement.
Only students graduating between June 2014 and May 2015 will be considered. All information must be typed on the form; handwritten copies will not be accepted. Only awards received while at current institution are applicable. (Awards from another college or high school should not be included.)
Student Nominee Information
Nominee Name:
Confirmation/Reference Number*:
* Note – confirmation/reference # will be provided after the information is submitted electronically
Campus: Stony Brook University
Graduation Date: / GPA:Degree: / Major:
Address (where you want your letter sent):
City: / State: / Zip:
Hometown (including zip code):
Email Address:
THREE MAJOR ACCOMPLISHMENTS OF STUDENT NOMINEE: Use the space below to list three major accomplishments. Example: President of the Student Association, Published an article and presented at a national conference, Regular volunteer at the local Humane Society
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Acknowledgement
I agree to allow the State University of New York to release information and/or a photo related to this award.
Signature of Nominee: ______
I support the nomination of this student for the Chancellor’s Award for Student Excellence.
Signature of Campus President: ______
*Please doublecheck that all information (contact email, address, etc) is correct before submitting form.
Nominee’s SBU ID#:
Completed* forms should be submitted to:
Chancellor’s Award Selection Committee,
Attn. Karen Kernan, Campus Representative
Melville Library N3005
Stony Brook University, Stony Brook, NY 11794-3357
Tel. 631.632.7114.
Fax. 631.632.4525.
Email:
Stony Brook Campus deadline is DECEMBER 19, 2014
* Applicant/nominee should sign page 1 of Form-Part A.1. (The signature of the campus president will be obtained once the 14 campus nominees have been selected).
BE SURE TO INCLUDE NAME, STONY BROOK UNIVERSITY on Nomination Form -Part A2 at top of page
Name of campus representative who is completing this form: Karen Kernan
Phone number: 631.632.7114 Email address:
Chancellor’s Award for Student Excellence 2015, Nomination Form – Part A.1