Submission Date *

MM

DD

YYYY

Nominator's Name *

First Name

Last Name

Is the nominator a current financial member of the Maroon and Grey Chapter? *

Yes

No

Nominee's Name *

First Name

Last Name

Nominee's Phone Number *

(###)

###

####

Is the nominee a confirmed graduate of Texas Southern University? *

Yes

No

Is the nominee a current financial member of the Maroon and Grey Chapter? *

Yes

No

Has the nominee been an active Chapter Member or Life Member for at least two (consecutive years prior to and including nomination and ballot voting year before being eligible to be placed on a ballot? *

Yes

No