Other Alumni Awards

AY 2019

NOMINATION FORM No. 2

This form must be accomplished by the nominee and the nominator

CATEGORY
☐ Loyalty Award ☐ Service Award ☐ Honorary Membership
Name of Nominee:
CLSU Degree: Year of Graduation:
Nationality: Date of Birth:
Home Address:

Telephone/Cellphone No.:
Fax No.: Email:
Agency/Company/Business Address:

Name of Nominator:
Home Address:

Institution: Position/Designation:
Telephone/Cellphone No.:
Fax No.: Email:
Agency/Company/Business Address:

Nominee’s Concurrence:

I accept the nomination and attest to the veracity of the foregoing data including

my presence/attendance to personally receive the award.

Nominee’s printed name and signature

Date

Reference:

This is to nominate for the 2019

CLSU Alumni Award

Name of Award

The nominee is known to me of good moral character.

Nominator’s printed name and signature

Date