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Academic Affairs Home
Syracuse Scholars Selection Committee
Syracuse Scholar Nomination
Student Nomination Form
Student Name _______________________________________
Syracuse University ID # ______________________________
Nominating School/College _____________________________
Dual School/College ___________________________________
Contact Person in School/College _________________________
Email Address ________________________________________
If I am selected as a Syracuse Scholar, I wish my name to appear in the program and on the medal
as ____________________________________________________.
My mentor is __________________________________________.
S/He has consented to being listed here.
Mailing Address in March (please notify the committee chair of changes):
Street _____________________________________________
City ____________ State ____ ZIP ___________
Telephone _______________
Parent(s) / Guardian(s) to notify:
Name _____________________________________________
Street _____________________________________________
City ____________ State ____ ZIP ___________
Telephone _______________
Name _____________________________________________
Street _____________________________________________
City ____________ State ____ ZIP ___________
Telephone _______________
I submit these materials as my own academic work.
I solemnly pledge that it is my intent to complete all work associated with any partial submissions included here.
I will notify the chair of the Syracuse Scholar Selection Committee if my address changes from that listed here.
Signature of Nominee ___________________________________
Date _____________________
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