TD Insurance Meloche Monnex Award for Outstanding Service

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					             TD Insurance Meloche Monnex Award
                   for Outstanding Service
                                          Nomination Form 2011

                        Nomination Deadline: 12:00pm, January 31, 2011
   The Graduate Students’ Association (GSA) Awards recognize evidence of excellence, leadership, and
 community involvement. Successful nominations will be acknowledged at the GSA’s annual Awards Night
                               ceremony to be held on March 10, 2011.

                                                  PURPOSE

  The purpose of this award is to recognize the contribution that graduate students make through volunteer
  service to the GSA, to the University of Alberta, and to the greater Edmonton and Alberta community. Any
                   current University of Alberta graduate student is eligible for this award.

                                                  CRITERIA

      □ Excellence of service to            □ Leadership in service to            □ Contribution to graduate
       graduate students and                 graduate students and                students, University, and to
        University community                  University community                the greater Edmonton and
                                                                                      Alberta community

                                                  SPONSOR

This award (valued at $500.00) is sponsored by Meloche Monnex. The award criteria as stated above reflect
Meloche Monnex’s continuing commitment to service, quality, integrity, innovation, and initiative. In addition,
the GSA is pleased to award $250 to two successful graduate students in second and third place. The GSA
portion of this award is sponsored by the AEGS fund (Academically Employed Graduate Students).

                                        MAKING AN APPLICATION

A Complete Nomination Package will contain three (3) copies of the following:
    Completed Nomination Form
    Condensed Curriculum Vitae of the nominee (must include service activities) (5 page maximum)
    Two Letters of Support from either a beneficiary of one of the nominee’s service activities or from
       an officer of a student group with whom the nominee has performed a service activity. In either
       case, the individual must be a member of the University community (1 page maximum)
    Self-nominations are accepted. Please complete and sign both the nominee and nominator
       sections on page two.
    It is the responsibility of the nominator to ensure the completeness and accuracy of the Nomination
       Package. Incomplete Nomination Packages will not be adjudicated. Any material exceeding the
       set page limits will be ignored.
    The GSA adjudicates all complete applications and will contact via email only those nominees that
       are successful. The application package will not be returned after submission.
    The GSA reserves the right not to give out this award to Graduate Students in any of the Tri-
       Council areas if a suitable candidate is not found.
                   TD Insurance Meloche Monnex Award
                         for Outstanding Service
                                                      Nomination Form 2011

                                                    Please TYPE or PRINT (ink only).
This personal information is being collected under the authority of the Personal Information Protection Act (PIPA).

NOMINEE INFORMATION
Surname:                                                                    Given Name:

Email Address:                                                              Masters or PhD Student:

Faculty:                                                                    Department:

Department Address:                                                         Department Telephone:


NOMINATOR INFORMATION
Surname:                                                                Given Name:

Relationship to Nominee:

Email Address:                                                          Home Telephone:

Faculty:*                                                               Department/Department Phone:*

* if applicable

Declaration: I hereby certify that the information in this application is true and is correct.

Date (MM/DD/YYYY): ____________________                     Nominator’s signature: _________________________________

Declaration: I hereby certify that the information in this application is true and is correct. I understand that all personal information
collected by the GSA about nominees is used to review applications, to administer awards, and may be used to provide a context for
the award at the GSA Awards Night and in GSA publications. If you have questions about the collection and use of your personal
information, contact the GSA at 780-492-2175.

Date (MM/DD/YYYY): ____________________                     Nominee’s signature: __________________________________


                  Send three (3) copies of the Complete Nomination Package to:
                                             Graduate Students’ Association
                                         1-37 Killam Centre for Advanced Studies
                                             Triffo Hall, University of Alberta
                                                  Edmonton, AB T6G 2E1
                                             Fax: 492-2999 Phone: 492-2175



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