The Delta Kappa Gamma Society International
Theta State Achievement or Merit Award

Deadline:  March 1st

Nomination for the Theta State ______________________________ Award
                                        (Write in the blank:    Achievement or Merit)

Name of Nominee ______________________________________________________________________________

Chapter ______________________________________________________________________________________

Address (home) ________________________________________________________________________________

_____________________________________________________________________________________________
                    (city)                                                    (state)                                                (zip code)

Date of Initiation _____________________________________ Chapter ____________________________________

Present Professional Status ________________________________________________________________________

Summary of Professional Contributions
                Activities:

                Honors:

                Leadership Positions:

Submitted by ____________________________________ Date __________________________________________

from the ________________________________________ Chapter of Theta State

Home Address _________________________________________________________________________________
                                                                            (use additional pages if needed)
Send completed form to Chairman of the Awards Committee: