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AY 2019
CATEGORY
☐ Loyalty Award ☐ Service Award ☐ Honorary Membership
Name of Nominee:
CLSU Degree: Year of Graduation:
Nationality: Date of Birth:
Home Address:
Telephone/Cellphone No.:
Fax No.: Email:
Agency/Company/Business Address:
Name of Nominator:
Home Address:
Institution: Position/Designation:
Telephone/Cellphone No.:
Fax No.: Email:
Agency/Company/Business Address:
Nominee’s Concurrence:
I accept the nomination and attest to the veracity of the foregoing data including
Date
Reference:
Date