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Sunday, April 21, 2019   11:10 AM    |   72°F

Hall of Fame Nomination Form

Name of nominee:

First:
Last:
Credentials:

Nominator name:

Primary:
Secondary:

Upload CV of nominee:

 (.docx, .doc, and .pdf only)

Summary bio of nominee (500 words or less to be published):

Describe the nominees enduring achievements (250 words or less):

Describe the nominees leadership (250 words or less) accomplishments:

Describe the specific outcomes related to the nominees leadership on health or social welfare (500 words or less):

Articulate the enduring nature of the nominees accomplishments and enduring impact on health and social welfare (500 words or less):

Describe the nominees relationship during their professional career with LSUHSC – SON (250 words or less):