Please complete the brief information below to nominate an Executive-in Residence at the College of Public Health. If you have any questions, please contact Vickie Miene.

Executive in Residence Nomination Form

Nominator name *

(Name of person completing this form)

Nominator email *

Nominator phone *

Executive in Residence nominee name *

Nominee title

Nominee Company/Organization *

Nominee phone

Nominee email *

Nomination

Why is this person a good match for the Executive in Residence program?