Hall of Fame Nomination Form

NOMINEE INFORMATION

Date *

Month

Day

Year

Nominee Full Name *

Affiliation with the ULM (formerly NLU/NLSC) College of Pharmacy? *

Alumni

Faculty

Staff

Friend of the College

If yes, which one? *

If alumni, degree? (if known)

Graduation year (if known)

Is the nominee living or deceased *

Living

Deceased

If deceased, can you provide contact person (name and email or phone number) for notification of nomination. *

Company/Business/Title for nominee *

Please describe the nominee’s significant professional achievements in pharmacy or pharmaceutical sciences (list any awards, honors or recognitions received if known). Include leadership roles, major accomplishments, awards, research contributions, or other professional milestones. *

Explain how the nominee has demonstrated service to the pharmacy profession. Examples: involvement in professional organizations, advocacy, public health initiatives, committee service. *

In what ways has the nominee supported or demonstrated commitment to the ULM College of Pharmacy and contributed to advancing the mission of the College? Examples: mentoring or precepting students, participating in alumni events, philanthropic support, speaking engagements, advisory roles. *

Describe the personal qualities that make the nominee a person of integrity who inspires pride and respect and share any examples that highlight the nominee’s character, leadership, or professionalism. *

NOMINEE CONTACT INFORMATION

Mailing Address

State *

City *

Zip *

Work or Home *

Home

Work

Email *

NOMINATED BY

Full Name *

Relationship to nominee *

Email *

Day phone *

Complete online form by May 31. If you would like to submit an additional letter of nomination, biographical data, CV, or any other supporting documentation (no more than 3 supporting documents), please email to Katie at kkelley@ulm.edu or mail to the address below by May 31.

Attn: Katie Scogin
ULM College of Pharmacy
1800 Bienville Dr.
Monroe, LA 71201

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