Alumni Council Award Nomination Form

It is understood that the information presented on this form will be treated confidentially in its use by the Alumni Awards Committee and the School of Medicine and Dentistry Alumni Relations Office and that any decision made by the Committee will be final. Please call 800-333-4428 with questions or concerns.


Choose an award for this nomination:


Alumni Achievement Award (2015)

Alumni Service Award (2015)

Distinguished Alumnus Award (2016)

Humanitarian Award (2016)

Nominee Information

Name:

School of Medicine and Dentistry Degree and Graduation Year:

School of Medicine and Dentistry Residency Year:

Mailing Address:

Phone Number:

Email:

Reasons for Nomination

Please describe in detail why this nominee is deserving of the award selected. What do you consider the nominee’s most important achievements? i.e. professional accomplishments, service to the community and/or School of Medicine and Dentistry, service to the poor and underprivileged. (If you prefer, this information may be submitted as a separate letter. Letters can be sent to the email or mailing address listed at the end of the nomination form).

Additional Education

Advanced Degree or Training

Residency

Year

Name of Institution

Present Profession

Employer

Occupation

Title

Nominator Information

Name:

School of Medicine and Dentistry Degree and Graduation Year:

Mailing Address:

Phone Number:

Email:

Your link to the nominee:

 

 

In addition to completing the above form, the nominating process requires the following additional materials:

  • Curriculum Vitae of nominee, summarized into a maximum of two pages. (If providing award information, please only submit the number awarded).
  • Maximum two letters of support from University of Rochester alumni or others
  • Maximum three additional documents, such as selected samples of writings by nominee, articles about nominee, or other information that will inform the committee

Nominating materials can be emailed to alumni@admin.rochester.edu or mailed to:

University of Rochester
School of Medicine & Dentistry
Alumni and Advancement Center
300 E. River Road, P.O. Box 278996
Rochester, New York 14627-8996

Questions? Please call the School of Medicine and Dentistry Alumni Relations Office at 800-333-4428.