ALUMNI AFFAIRS OFFICE
NOMINATION FORM
Search for 25 TSU Distinguished Alumni
Name of Nominee: _______________________________________________________________
Degree/s Earned from TSU:
Degree Year Graduated
Field of Specialization/Expertise:
______________________________________________________
Home Address:
______________________________________________________________________
Landline: ______________________Mobile: ______________________Fax:
____________________
Email Address:
______________________________________________________________________
Date of Birth: __________________Place of Birth:
_________________________________________
Nationality:
_________________________________________________________________________
Civil Status: ( ) Single ( ) Married ( ) Separated ( ) Widowed
If married, name of spouse:
___________________________________________________________
Occupation/Profession:
______________________________________________________________
Name of Employer/Company:
________________________________________________________
Current Position/Designation:
________________________________________________________
Number of Years in the Position/Designation:
__________________________________________
Academic Background:
School Attended Degree Earned Inclusive Dates
Form No.: TSU- AAO-SF- 02 Revision No.: 00 Effectivity Date: June 28, 2016 Page 1 of 4
ALUMNI AFFAIRS OFFICE
Employment History (if applicable):
Name of Position Inclusive Dates
Employer/Company
Address
Researches and/or publications/inventions/innovations, if any:
Title of Research Name of Date of Publication
Publication/Journal
Honors, awards or recognition, if any:
Award Recognizing/Awarding Year Awarded
Body
Address/Contact No.
Membership in professional, civic, and other organizations, if any:
Name of Organization Position Inclusive Dates
DESCRIPTION OF THE WORK, ACHIEVEMENT, ACCOMPLISHMENT OR PERFORMANCE
ON WHICH THE NOMINATION IS BASED: (use additional sheets if necessary)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Nominator: ____________________________
(Signature over Printed Name)
Position/Designation: ______________________________________________________________
Postal Address: _______________________________ E-mail Address:
_____________________
Form No.: TSU- AAO-SF- 02 Revision No.: 00 Effectivity Date: June 28, 2016 Page 2 of 4
ALUMNI AFFAIRS OFFICE
Landline: _____________________Mobile: _____________________ Fax No: ________________
The following must be attached to the nomination form:
1. Photocopies of:
Diploma, graduate units
Certificate of attendance in trainings/seminars/conferences, etc.
Appointment Papers
PRC License or other similar documents
Professional Leadership Award
Community service, projects, awards
Published articles (with pertinent Table of Contents of publication),
copyrights, patents
2. Two (2) recent 2x2 size colored picture with white background of the
nominee
3. Other documents deemed necessary to support the nomination
SELF CERTIFICATION
I hereby certify that I am not charged and have not been charged of
any administrative and/or criminal case in any court, tribunal and/or
administrative body, nor was I convicted of any criminal or administrative
offense.
I hereby certify further that all data/information given in this
nomination form are true and correct and that all supporting documents
submitted are authentic.
This certification is issued in connection with my nomination for the
search of Outstanding Alumni of Tarlac State University.
Done this ____ day of __________ 2016.
_______________________________________
Signature over Printed Name of Nominee
Form No.: TSU- AAO-SF- 02 Revision No.: 00 Effectivity Date: June 28, 2016 Page 3 of 4
ALUMNI AFFAIRS OFFICE
Form No.: TSU- AAO-SF- 02 Revision No.: 00 Effectivity Date: June 28, 2016 Page 4 of 4
