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: ____________________