Date

I am:
female
male
a member of a team

Full name of person or group:

Hometown address including city, county, state and zip code:

High school and city with date graduated:

Local Address:

Local Phone:

Your major:

Year in School: freshman sophomore junior senior graduate

If a group, list names of all group members:

My nomination is for:
Dean's Honor Roll Aggie of the Year Family-Consumer Scientist of the Year Outstanding Freshman Outstanding Ag. Junior Outstanding Junior Family-Consumer Scientiest Outstanding Senior M.C. of the Awards Program Outstanding Club Undergraduate Research Project

Additional information/reason for story/pictures if available:

Mother's name and full address:

Father's name and full address:

List additional activities, honors, or awards while at WSU and additional information you think might add to the story. Use other side if necessary.

Hometown daily or weekly newspapers and towns:

Hometown broadcast stations:

By submitting this form, I grant permission to Washington State University (WSU) to publish my/my team's story and/or picture for use in promotional, educational, display or other media publications including newspapers, magazines, television, brochures, pamphets, instructional material, books, web pages and/or other educational material.

For team applications, that this signed agreement applies to all group members. I understand that electronically completing this form by typing my name below constitutes a signature. If completed manually, I will sign the form for myself and group members, using black or blue ink.

My signature:

Please print this page and include with award/display application(s).