Nomination Form

Please complete and submit the requested information.

(* Required)
Nominee
First Name *
Last Name *
Maiden Name (if applicable)
Home Address
City
State
Zip
Home Phone
Work Phone
Year of Graduation
Award Category *
Nominator
First Name *
Last Name *
Phone *
Email
Address
City
State
Zip
Class Year (if applicable)
Relationship to Nominee *
Please include a summary of accomplishments which will provide a basis for the nomination. *
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Contact Us

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Alumni Relations Office
Alumni Hall, Ground Floor
Mansfield, PA 16933
Phone: 570-662-4390
Toll Free: 888-305-6505
Email: alumni2@mansfield.edu

Denise Berg, Director
Tracey Dukert, Assistant Director

University Advancement Office
524 North Hall
Mansfield, PA 16933
570-662-4292