EMPLOYEE RECOGNITION PROGRAM

NOMINEE INFORMATION FORM

Click or tap to enter a date.

Person nominated:

Name	Click or tap here to enter text.	Title	Click or tap here to enter text.
Department	Click or tap here to enter text.	Campus Phone	Click or tap here to enter text.

Person making the nomination:

Name	Click or tap here to enter text.	Title	Click or tap here to enter text.
Department	Click or tap here to enter text.	Campus Phone	Click or tap here to enter text.

References: List at least one, but no more than three references who support this nomination. These references should be notified that they may be required to furnish a letter of recommendation. The person making the nomination should submit a letter providing specific examples that support each of the SIX criteria with the nomination application. PLEASE NOTE: The nomination must be made or supported by the supervisor. The supervisor must submit a letter of support at the time of the nomination. Persons listed as reference are not required to submit a letter at this time and will only be asked to do so if needed.

Name	Click or tap here to enter text.	Title	Click or tap here to enter text.
Department	Click or tap here to enter text.	Campus Phone	Click or tap here to enter text.

Name	Click or tap here to enter text.	Title	Click or tap here to enter text.
Department	Click or tap here to enter text.	Campus Phone	Click or tap here to enter text.

Name	Click or tap here to enter text.	Title	Click or tap here to enter text.
Department	Click or tap here to enter text.	Campus Phone	Click or tap here to enter text.

For use by Office of Human Resources only:

Two-year requirement in position met?	☐	Yes	☐	No

Received EOM in the last five years?	☐	Yes	☐	No

Did supervisor supply letter?	☐	Yes	☐	No

Service date _____________ Years of service _____________ Date received _____________

Date submitted to committee for review ______________________________

Reason for hold __________________________________________________

Date additional information requested ______________________ Of whom _______________

Date additional information received ______________________ Total Score _______________