Nominee Information:
Name:
Title:
Institution:
City:
State:
ZipCode:
Phone:
Email:
Please List number of years in the research administration field.
Select status:
List service involvements in a regional or national NCURA Committee, including serving as an officer at the regional or national level.:
List regional or national participation as a presenter, panelist, or moderator:
Nominees should evidence a quick willingness to offer their abilities, time, commitment and enthusiasm to Region VI. (Please explain):


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2 Nominators are required. Please enter their information:
Nominator Name:
Nominator Name
Title:
Title
Institution:
Institution
Email:
Email:
Email:
Email:
       

An award recipient's immediate supervisor and/or president of the recipient's institution will receive notification of the award presentation.
Supervisor Name :
Institution President Name:
Title:
Title:
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Phone :
Phone: