CCSU Alumni Association
2016 Alumni Aw
ards Nomination Form
PLEASE SAVE THIS FILE, THEN EMAIL OR PRINT & FAX THIS FORM TO:
CATHERINE JOST, JOSTC@CCSU.EDU, FAX: 860-832-2585
The following awards are instituted to recognize alumni and friends of CCSU or its predecessors who have made
signicant contributions to help advance the mission of the university and bring positive recognition to Central
Connecticut State University.
Distinguished Alumni Award
The Distinguished Alumni Award is presented to a graduate of Central Connecticut State University for outstanding
professional and/or personal achievements, bringing credit to himself/herself and, in turn, credit to Central
Connecticut State University.
Young Alumni Award
The Young Alumni Award is presented to a graduate of Central Connecticut State University in recognition of
professional and/or personal achievement. The recipient shall be 40 years of age or younger.
Community Service Award
The Community Service Award may be presented to a graduate for extraordinary community service, and for
contributions that advance the improvement of society, thereby reecting favorably on the University.
Friend of the University
The Friend of the University Award may be presented to a non-graduate of the University who has provided
distinguished leadership and/or service to Central Connecticut State University. Friend may include an individual;
organization; corporation; or member of Central’s faculty or staff.
Your Contact Information:
Full Name:
Phone:
E-mail:
Award Nominee Full Name:
Address:
City:
State:
Zip:
Phone:
Country:
Email:
Business/Company Name:
Job Title:
Graduation Year:
Professional Achievements:
Service to CCSU/Alumni Activities:
Awards/Honors:
PLEASE MARK A CHECK NEXT TO THE NOMINATION AWARD CATEGORY
