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Chancellor’s Leadership Award Nominee Questionnaire


Please complete the following questionnaire completely and in detail as your answers will be reviewed by the selection committee and will determine your level of leadership and involvement on campus.


The nominee questionnaire form is due by 8:00am Monday October 26, 2009.
If you have any questions, please email or call Dana Mallett in the Alumni Affairs office at 715.346.3813

NOMINEE FORM

Personal Information

Last Name First Name Middle Initial

Phonetic spelling of last name (ex: Adams = Add-ums):

Local Address:

Email:

Parent(s) Name:

Home Address:

Name of Spouse (if applicable):

Name(s) of children (if applicable):


Education

Major area(s) of study:

Minor area(s) of study:

Cumulative Grade Point Average (GPA) :

Anticipated date of graduation :

1) Please list the campus activities in which you VOLUNTEERED while in college:

Organization or Activity Office held (if any) Semesters participated
(semester & year
ex: semester 1 of 2009)		 Level of responsibility:
1= Low 2= Medium 3= High

2) Please list the campus activities you participated in that were PAID POSITIONS while in college:

Organization or Activity Position Semesters in Position

3) List any honors or recognitions you have received while in college (e.g., scholarships, awards, articles published in journals or magazines, etc.)

4) List any additional responsibilities or accomplishments which could be considered by the Selection Committee (Teaching Assistant, tutoring, Orientation Leader, Residence Hall staff, community or hometown activities while in college, etc)

5) For the purpose of this award, the university has been using a broad definition of leadership put forth by Warren Bennis and Burt Nanus who suggest that leaders are people who:

- Have a strong sense of purpose - Are magnetic and draw in others
- Are very persistent - Treat others with respect and caring
- Seek to know themselves - Take risks and like to experiment
- Are always learning - Sees mistakes as opportunities
- Find a sense of joy in their work - Serve the needs of others

How do you feel your involvement on campus meets or exceeds this definition? Please be specific in your explanation as your answers will be used as a determining factor of your involvement.

6) We define campus/community service as the unselfish giving of oneself in the serving of common good of our campus/community, and the quality of an individual’s response to membership or citizenship through their campus/community contributions.

In what ways do you feel your campus/community service meets or exceeds this definition?

7) We define personal growth as the degree to which students have attended workshops, participated in seminars, demonstrated mature decision-making/problem solving abilities, and participated in campus/community experiences which demand graduated amounts of personal or professional sophistication.

How would you say your personal growth experiences on this campus meet or exceed this definition?

If chosen as a recipient of the Chancellor’s Leadership Award or the Albertson Medallion Award, how would you like your name inscribed on the medallion?

If selected as a recipient of the Chancellor’s Leadership Award or the Albertson Medallion Award, I grant permission to release the information I have provided on the questionnaire.


Thank you for your time in submitting your questionnaire for the Chancellor’s Leadership Award and Albertson Medallion Award. If you have any questions, please email or call Dana Mallett in the Alumni Affairs office at 715.346.3813.