Nomination Form

Distinguished Alumni Award

Nomination Form

Nominator Contact Information
Nominee Contact Information
Additional Supporter
Nomination Package - Due Mon. March 31, 2014

Each Nomination Package submitted must include the following:

Nominator's Information
Nominee's Curriculum Vitae
Support Statement Form
Nominee Release Form

Any additional supporting materials are also welcome.

Please upload a copy of the Nominee's Curriculum Vitae.

The nominator is asked to attach a completed statement of support using the following questions as a guideline.
(Maximum of 2 typed pages in length)

1. What exceptional contribution has the nominee made to his/her profession?

2. What awards or honours has the nominee received for his/her personal and professional contributions and accomplishments?

3. How has the nominee embodied the criteria/rational of this award into his/her personal and professional life?

4. How has the nominee contributed to society and served the community?

5. In what ways can the nominee be considered an inspiration to current students?

Download Nominee Release Form

The Brock Universtiy Alumni Association requires all Award Nominees to sign a Release Form to indicate they have read and understand the Nomination Agreement.

Please download the Nominee Release Form and have your Nominee Read and Sign the Release Form. The form can then be uploaded as a file and submitted with this Nomination Package.

Nominator Agreement

You agree to allow the information provided in the nomination package and other information gathered for this purpose to be used by the Brock University Alumni Association and/or Brock University Office of Alumni Relations for publicity and promotional purposes in accordance with the Freedom of Information and Protection of Privacy (FOIP) Act.

Thank You!

Thank you for taking the time to Nominate a Distinguished Alumni.

If you would like more information about the Alumni of Distinction Award or have any questions about filling out this Nomination Form, please contact the Alumni Association office at (905) 688-5550 ext 3838 or email