Student of the Month Nomination Form

Please complete the following fields to nominate a student for this award.

Upon submission, the form will be sent to the Penn State Hazleton Committee on Student Relations, who will vote to determine the winner.

First name of student nominee:

Last name of student nominee:

General category for nomination (Check all that apply)

Civility

Academic Performance

Academic Improvement

Community Care and Involvement

Personal Achievement Over Obstacles

Other (please specify below)

Reason for nomination (Please be specific):

First name of nominator (optional):

While this information is optional, please complete this section in case the committee has questions about the nominee.

Last name of nominator:

Nominator's email:

Nominator's cell phone number:

Date submitted:

Note: The date should reflect a date prior to or the last date of the month in which the student is being nominated for the award.

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