Name of Nominating Group:

Nominating Group Contact Person:
Phone Number of Contact:
Email of Contact:

Name of Nominee:

Phone Number of Nominee:
Email of Nominee:
Local Address of Nominee:

Major(s), Minor(s):

Name of Parents:

Address(es) of Parents:

Name of High School and Graduation Year:

Extra Curricular Involvement and Activities at MSUM:

Service Involvement:

Scholarships/Honors/Awards:

Main Life Goals:

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