SAINT LOUISUNIVERSITY

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 LouisUniversity. These men and women shall have achieved outstanding success:

in their personal home, and family life; (include service in Parish, Church,

Synagogue or religious societies)

or in their professional life;

or in their civic leadership or social welfare activities; (include offices held in

Civic, Fraternal, Political, Labor or Community Groups)

or in their intellectual or cultural pursuits (list memberships in Learned or Cultural

Societies, articles published, books written, etc.)

Note: Full-time Saint LouisUniversity 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 at the time of its presentation.

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 namemiddle initiallast name

Home Address:______

______

Business Address:______

______

Phone:(Home) ______(Business): ______

Education and degrees received from Saint LouisUniversity:

School/College of ______Degree ______Year Rec'd ______

School/College of ______Degree ______Year Rec'd ______

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 LouisUniversity.

______

Please include a complete biographical sketch, CV, profile, etc. with your nomination.

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

Submitted by:______

first namemiddlelast name

Signature:______

Address:______

Date Submitted:______

Nominations must be submitted by April 19, 2013.

Please mail nomination to: Attn: Cheryl Byrd, Saint Louis University, Medical Center Alumni Relations Office, 3545 Lafayette Avenue, 6th Floor, St. Louis, MO 63104. Nominations also accepted via e-mail to .