Please read the form carefully

NOMINATOR CONTACT INFORMATION

Name:
Address:
Address 2:
City:
State:
E-mail
Employer
Phone Home:
Phone Work:

I certify that the nominating information I am supplying is accurate to
the best of my knowledge.

NOMINATION

Category in which you are making the nomination:

Distinguished Nurse Administrator
Distinguished Nurse Educator
Distinguished Nurse Researcher
Lifetime Achievement in Nursing
Alumni Nurse Leader

NOMINEE CONTACT INFORMATION

Name
Address
Bldg. or Apt. #
City
State
Employer
Position:
Home Phone
Work Phone

NOMINATION NARRATIVE

In a separate e-mail to sharon_dilg@mail.msj.edu, please attach a narative that
addresses the Award Criteria for the individual you are nominating. Include specific
examples of how the nominee meets the criteria.
Please DO NOT mention the name of the nominee, nor place of employment in the narrative.
Also submit a curriculum vita of the nominee with the narrative.

This narative and vita can also be faxed to 513-451-2547 or mailed to:
Leadership in Nursing Awards Program
Health Sciences Department
College of Mount St. Joseph
5701 Delhi Road
Cincinnati, OH 45233-1672