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Please note that all items indicated with * are mandatory

*First Name:
*Last Name:
MI:
*Home Address:
*City:
*State:
Telephone:
Fax:
Email address:
*Class Year or year(s) attended the University of Maryland:
Major(s):
Degree(s):
*Education other than at University of Maryland:
*Business/profession:
Title:
Business Address:
City:
State:
Business Telephone:
Fax:
*Current University of Maryland Activities:
University of Maryland Activities as a student:
*Business, professional, community service, honors, awards or achievements
Please include any more information that may be helpful to the Nominating Committee:
Your information: (items indicated with * are mandatory)
*Last Name:
* First Name:
MI
*Class Year or years attended:
*Preferred Address:
* City:
*State:
*Zipcode
*Preferred Telephone:
Preferred Email: