School of Medicine & Dentistry / Alumni / Alumni Awards / Awards Form

Alumni Council Award Nomination Form

It is understood that the information presented on this form will be treated confidentially in its use by the Alumni Awards Committee and the School of Medicine and Dentistry Alumni Relations Office and that any decision made by the Committee will be final. Please call 800-333-4428 with questions or concerns.

Award

Award Name:

Alumni Achievement Award
Alumni Service Award
Distinguished Alumni Award
Humanitarian Award

Nominee

Name:

School of Medicine and Dentistry Degree and Graduation Year:

School of Medicine and Dentistry Residency Year:

Mailing Address:

Phone Number:

( ) -

Email:

Reason For Nomination:

Additional Education

Advanced Degree or Training:

Residency:

Year:

Name of Institution:

Present Profession

Employer:

Occupation:

Title:

Nominator Information

Nominator Name:

School of Medicine and Dentistry Degree and Graduation Year:

Nominator Mailing Address:

Phone Number:

( ) -

Email:

Your link to the nominee:

Our Privacy Policy

In addition to completing the above form, the nominating process appreciates the following additional materials:

Curriculum Vitae of nominee, summarized into a maximum of two pages. (If providing award information, please only submit the number awarded).
Letters of support from University of Rochester alumni or others
Additional documents, such as selected samples of writings by nominee, articles about nominee, or other information that will inform the committee

Nominating materials can be emailed to smdalumni@rochester.edu or mailed to:

University of Rochester
School of Medicine & Dentistry
Alumni and Advancement Center
300 E. River Road, P.O. Box 278996
Rochester, New York 14627-8996

Questions? Please call the School of Medicine and Dentistry Alumni Relations Office at 800-333-4428.