Fred Ellsworth Medallion

Nomination Form

Thank you for your nomination. To complete this process, please fill out the form below and mail or fax a letter addressed to the Fred Ellsworth Medallion Selection Committee that details your nominee's qualifications.

Mail:
Attn: Fred Ellsworth Medallion Selection Committee
Adams Alumni Center
1266 Oread Avenue
Lawrence, KS 66045-3169

Fax:
785-864-5397

Nominations will be accepted through March 31, 2010.

Please provide the following information.

*= Required Field

Nominee Information
Name *
Address *
City *
State/ Province/ Region *
ZIP Code/ Postal Code (If applicable)*
Country *
KU Class/Year
Membership in the KU Alumni Association (required): (Annual/Life/Jayhawk Society)

Past Service and Offices Held Include Dates When Known
Alumni Association:
National Chair
Executive Vice Chair
Board of Directors
Chapter Leadership
Committees
Kansas Honors Program Leadership
Hawk to Hawk Mentor
Other events or special programs

Endowment Association:
Chairman/President of Trustees
Board of Trustees
KU First Campaign
Campaign Kansas
Greater University Fund Advisory Board
Chancellors Club
Other events or special programs

Athletic Corporation:
Chairman of the Board
Board of Directors
Williams Educational Fund
Other events or special programs

Chancellor's Office:
Office of External Affairs
Adviser/Volunteer
Other events or special programs

School & College:
Advisory Committee
Student recruitment and/or mentoring
Other events or special programs

Office of Admissions and Scholarships:
College night volunteer
Other recruitment assistance

Additional Information:
Previous honors
Please list Web sites or other sources of additional information and attach newspaper clippings or other documentation available.

Nominator Information:
Nominated by
Address
Phone
E-mail
Date
Miscellaneous Comments

Your nomination will be forwarded to the selection committee after your letter is received.