Nominate Distinguished Alumnus

My nominee for the Distinguished Alumnus Award is:

Nominee’s Name*

Address*

City*

State*

Zip*

Current Telephone*

Year of MPTC Graduation*

Program of Graduation*

Current employer and occupation:

Job Title*

Employer Name*

Employer Address*

City*

State*

Zip*

Service to Moraine Park Technical College since graduation:*

Demonstration of support of Wisconsin Technical Colleges through his/her time and talent:*

Demonstration of noteworthy accomplishments in his/her field:*

Demonstration of service to his/her community through civic, religious, charitable, business, professional or other means:*

Demonstration of his/her personal continuing education program goals and accomplishments:*

Demonstration whereby he/she uses Wisconsin Technical College educational services in his/her occupation:*

Demonstration of role technical education has played in his/her career and personal life:*

Please state why you feel this individual deserves recognition as a distinguished alumnus.*

Please list two people who could be contacted for additional information.

Name*

Address*

City*

State*

Zip*

Phone*

Email*

Name*

Address*

City*

State*

Zip*

Phone*

Email*

I certify that the above information is true and accurate to the best of my knowledge.

Nominator*

Address*

City*

State*

Zip*

Phone*

Email*

Date*

How did you hear about this nomination opportunity? (Newspaper, Facebook, electronic sign, etc.)*

Nominate Distinguished Alumnus

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