Potomac State College

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Alumni Achievement Award Nomination Form

Award Description:

The Potomac State College Alumni Achievement Award is granted for distinguished service and exceptional
accomplishment in any field of endeavor that brings honor to the recipient and his/her Alma Mater. The
recipient should be outstanding in his career or profession, be involved in civic activities, humanitarian causes,
and/or creative endeavors in the arts.

I hereby nominate the following individual as a candidate for the
Potomac State College Alumni Achievement Award:

Candidate Name:
Candidate Street Address 1:
Candidate Street Address 2:
Candidate City:
Candidate State / Province:
Candidate Zip / Post Code:

In what way is the candidate outstanding in his/her field?

Please complete the following if you can:

(a) What are the candidate's professional qualifications?

(b) What positions has the candidate held in organizations affiliated with his or her field?

(d) What are the candidate’s accomplishments in local, national, or international government?

(e) What additional areas of achievement reflect on the candidate and Potomac State College?

Nominator Name:
Nominator Street Address 1:
Nominator Street Address 2:
Nominator City:
Nominator State / Province:
Nominator Zip / Post Code:
Nominator Phone:


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