The Chair Academy: 2010 Exemplary Leader Form

Please submit the following information for your recognition:

Exemplary Leader's Information:

Name:
Title/Position:
College Name:
Address:
City, State, Zip:
Phone Number:
Email:

Please provide us with a brief paragraph illustrating several examples in which the leader or team of leaders exhibited academic and administrative excellence, and thus why they should be recognized by the Chair Academy as an Exemplary Leader. (no more than 75 words - Please submit summary in its final printable form, as the summary will be printed in the exemplary leader booklet as it is submitted to us.):

Nominator's Information:

Name:
Title/Position:
Phone Number:
Email:

Other Information:

College President's Name:
Phone Number:
Email:

Individual or team name as it should appear on the award:

Will the nominator be present at the conference?
yes no

Will the exemplary leader(s) be present at the conference?
yes no

Please send a “high resolution” digital picture (shoulder shot) in .jpg format, not to exceed 8x10, to chairacademy@aol.com for inclusion in the Exemplary Leader booklet which will be distributed at the Conference, for inclusion in the summer Leadership journal, and for placement on the Chair Academy’s website.

Note: the exemplary leader(s), or their nominator, must be present at the conference to receive the award.

Deadline to submit nomination: December 21, 2009