Maynard K. Hine Award

Nomination Form

**Indicates Required Fields

Nominee Information

**First Name

**Last Name

Degree and year graduated from IU

Degree(s)

Degree Year

Degree and year graduated from Purdue

Degree(s)

Degree Year

Degree and year graduated from another university

Degree(s)

Degree Year

Home address

Street Address

Street Address 2

City

State

Zip

Home Phone

Business address

Street Address

Street Address 2

City

State

Zip

Business Phone

Present Occupation

Please list any memberships in professional, business, civic, social, and similar organizations

Organization #1

Organization #2

Organization #3

Note: Since this award "recognizes significant contributions to Indiana University-Purdue University Indianapolis," please include specific examples of nominee's achievements relative to this campus.

Service by nominee on boards, committees, and/or organizations at the department, school, campus, state, or national level

Achievements by nominee in his/her chosen field of endeavor, such as law, medicine, dentistry, nursing, business, social work, etc.

Additional information pertinent to nominee's qualifications for Maynard K. Hine Medallion

About You

**First Name

**Last Name

Street Address

Street Address 2

City

State

Zip

**Telephone (Day)

**Email Address

Download form to print out and mail in here.

Nominations should be submitted by November 18th
*Questions? Contact Yvonne Owens:

IUPUI Office of Alumni Relations
Phone: 317-274-5063
E-Mail: yowens@iupui.edu