Wisconsin Academy Fellows Nomination Form

Please fill out the following form completely. Nominations that are not successful for 2011 will be retained by the Academy and automatically reconsidered in each year's selection process for up to three years following the initial nomination. Nominators may submit revised information if they wish to do so, but that will not be required for reconsideration of the candidate. Nominators are welcome to submit additional materials-such things as publications, images of art works, and letters of support-in addition to this form. Please send additional materials in digital format to gkohl@wisconsinacademy.org or via post to Fellows Selection Committee, 1922 University Ave., Madison, WI 53726. Please reference the nominee when sending additional materials.

The nomination deadline for the 2011 Wisconsin Academy Fellows is February 1, 2011.
Thank you for your nomination.

NOTE: You must complete all required fields before submitting form.
Submission with incomplete fields will cause the entire form to reset.

Please complete all required fields.

Date

Candidate's Name (first, middle, last):

Candidate's Professional Title and Affiliation:

Address:

Business Phone:

Home Phone:

E-mail:

Date and Place of Birth (optional):

Education:

Positions Held:

Nominator's Name (first, middle, last):

Nominator's Address (street, city, state, zip):

Nominator e-mail

CITATION, 50 WORDS OR LESS (A succinct statement such as could be used at the time of induction of a successful candidate.)

AWARDS AND HONORS

250-WORD STATEMENT (Summarize the main reasons for nomination. Achievement in some area is the main criterion, but interests beyond one's specialty and service to the state and society at large may also be a consideration.)

MAJOR ACHIEVEMENTS (Describe in more detail the work for which the candidate deserves to be elected as a Fellow.

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