Your Name: *
Your Email: *
Your Phone #: *
Your class year:
Your address: *
Your city: *
Your state: *
Your zip: *
First Name: *
Middle/Maiden Name:
Last Name: *
Class Year: *
Current Address:
City:
State:
Zip:
Daytime Phone:
Evening Phone:
Email:
Birth Date:
Place of Birth:
Deceased? yes or no yes no
Graduation year:
Major:
Other College:
Sport #1:
Years played:
# of letters:
Years as captain:
Individual honors:
School Records:
Team Honors:
Sport #2:
Sport #3:
Sport #4:
(nominee's occupation, community involvement, post-college athletic achievement, or additional comments):