GPSA - Application Pg. 4

GPSA Office
P.O. Box 413
Pueblo, CO 81002

GPSA Room
Massari Arena
CSU-Pueblo
Pueblo, CO 81007

Hall of Fame Wall
Thatcher Building (Main Floor)
5th and Main
Pueblo, CO 81003

Top Panel

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Official GPSA Nomination Form Page 4

Nominee's Information

First Name

Submission Date

Nickname

Does the nominee have a nickname?

Middle Name

Do you know the Nominee's middle name?

Last Name

Nominator's Information

Name

Who is nominating you to the GPSA?

Email Address

Please input the nominator's email address (correctly) please.

Nominee's Contributions

LIMIT TO THIS SIDE OF PAGE ONLY… THANK YOU!
Examples:
List contributions as a leader, speaker, writer, innovator or elected/appointed officer or committee member made by the nominee which impact on the state and national level.
If none, Please indicate NONE below.

Nominee's Contributions

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GPSA Locations

Official GPSA Nomination Form Page 4

Nominee's Information

Nominator's Information

Nominee's Contributions