The Bastyr University Awards Programs

Nominations for the 2009 awards will be accepted until 5 p.m. on Friday, October 9, 2009.

*Indicates a required field.

Your Name

First Name:*		Last Name:*
Street Address:*
Address 2:
City:*		State:*
Postal Code:*
Daytime Phone:*		Fax:
Evening Phone:*
E-mail:*

Your affiliation with Bastyr University
Select as many as apply. At least one is required.*

Alumni Faculty Administration Staff Contributor/Supporter Other

Nominee

Please enter the contact information of the person you are nominating.
Name of Nominee:*
Title, Status or Profession:*
Home Address:
Address 2:
City:		State:
Postal Code:
Phone:		Fax:
Email:
Degree, Year, University, College or School:

Business Address (if applicable or different from nominee home address above)
Business Address:
Address 2:
City:		State:
Postal Code:
Phone:		Fax:
Email:

Award Nomination

Please select one: *

Dr. Les Griffith Student Award
Dr. Joe Pizzorno Alumnus/a Award
Dr. Bill Mitchell Service Merit Award
Sheila Quinn Service to Society Award

How is this candidate involved with Bastyr University:*

List the candidate's other affiliations and awards:

Civic Affiliations:

Professional Affiliations:

Awards:

What is the professional background of the candidate?

In addition to the above information, please provide a detailed description of how your candidate's qualifications fulfill the criteria for the award category for which he or she is nominated:*

Any additional information (magazine articles, CV, resume, photos, etc.) may be mailed to:

Bastyr University
Attn: Awards Committee
14500 Juanita Drive NE
Kenmore, WA 98028-4966

Please be sure to include your name and the name of the nominee.

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