NOMINEE INFORMATION

Last Name:

First Name:

Middle Initial:

Maiden Name (if applicable):

Address

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Phone Number

###

###

####

Email Address

Graduation Year:

NOMINATOR INFORMATION

Last Name:

First Name:

Middle Initial:

Address

Street Address

Street Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Phone Number

###

###

####

Email Address

Graduation Year:

DEPAUW STUDENT ATHLETIC ACHIEVEMENT/RECORD (INDIVIDUAL OR TEAM)

Please provide a brief explanation of the qualifications of this nominee for the Athletic Hall of Fame. Please use your own words to list relevant accomplishments or other recognition. Please note selection is based on their athletic accomplishments during their years as a 창벎77르적 student athlete.