Attachment I


Nomination Form for Mariel M. Muir Excellence in Mentoring Award



Name of Nominee:              ___________________________________________


Rank/Job Title/Position:      ___________________________________________


Department/Office:              ___________________________________________


College/Division:                 ___________________________________________


List of Mentoring Activities on Campus (in chronological order with specific dates):





Other Assignments related to Mentoring (for example: committee memberships, involvement in campus organizations, professional advisory roles, etc.):





How did the mentor assist the student, faculty or staff to function effectively in the organization? (Give examples)





How did the mentor exhibit a sustained commitment to their professional relationship with the student mentee that resulted in the mentee’s career growth or personal development? (Describe)





What behavior, attitudes, and skills did the mentor demonstrate to assist the mentee in achieving competence, confidence and a professional identity? (Give examples)




Nomination by/Contact Person:__________________________________________


Signature:                                                                             Date: ____________________