Georgetown Dental Alumni Awards Nomination Form

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Please complete the form below and include the nominee's curriculum vitae and a letter of recommendation in order for the candidate to be considered. Email supporting documentation to Naomi Weitz, coordinator, GUMC Engagement & Annual Giving, at gumcengagement@georgetown.edu.

The deadline for nominations is Friday, January 27, 2017.

Nominee Name:

Award

DSA - Distinguished Service Award

Kruger Lifetime Achievement Award

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Georgetown School(s) and Class Year(s):

Home Address, City, State, Zip:

Phone number:

Email address:

Place of Business & Position:

Work Address, City, State, Zip:

Georgetown Support & Participation

class leadership roles, reunion volunteers, club or council members, alumni club or board participation

Professional Accomplishments & Activities

Supporting Documentation

Email to Naomi Weitz at gumcengagement@georgetown.edu

Curriculum Vitae

Letter of Recommendation

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Your Name *

Your Email *

Submit

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