NOMINATION FOR OUTSTANDING SCHOLAR—COLLEGE-LEVEL

FY 2021

Submission Deadline: Wednesday, April 7, 2021 by 4:00 p.m.

Directions: ALL of the information requested must be supplied. Electronic submission of all parts of the application is required (in one, collated pdf file) and must be sent to Kristi Katcher, at kkatcher@siumed.edu.

NOMINEE:

Typed Name:	Faculty Rank/Title:

DEPARTMENT:

MAIL CODE & PHONE NUMBER (if Springfield) or COMPLETE ADDRESS (if Carbondale/Decatur/Quincy):

____________________________________________________________________________________________________________

NAME OF NOMINATOR:

Typed Name:	Faculty Rank/Title:

NOMINATOR’S DEPARTMENT:

NOMINATOR’S MAIL CODE & PHONE NUMBER (if Springfield) or COMPLETE ADDRESS (if Carbondale/Decatur/Quincy):

Checklist of items to include:

Nomination Letter

CV of Nominee

Reference Letters, if any