Nominee's Name *

First Name

Last Name

College or University Address *

Address 1

Address 2

City

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Is the nominee a member of the Mathematical Association of America?

Yes

No

Unsure

Has the nominee taught at least half time in a mathematical science during the current academic year or during the previous year if on approved leave or sabbatical?

Yes

No

Unsure

Nominator Name

First Name

Last Name

Nominator Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Nominator Phone

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