| Year graduated from UAMS or years of service with UAMS: |
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| Education: |
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| Professional memberships/committees, etc: |
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| Business/professional honors, awards or achievements: |
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| Community service, honors, and awards: (include civic, religious, youth and philanthropic activities): |
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| Information about nominee's family: (partner's name, partner's business/ profession, etc., number of children, name[s] and age[s] of children): |
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| Please list here additional information concerning the nominee which you feel may be helpful to the hall of fame committee in making its selection: |
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| Nominator's statement regarding why the nominee should be selected as hall of fame member: |
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