Nominee:

Institution:

Person submitting this form:

Course(s) I have taken with this instructor:
 
 

Year in which I was last enrolled in a course offered by the nominee:

My current occupation is closely/indirectly/not (cross out all but one) related to the subject(s) taught by this instructor.

Compared to other college instructors with whose teaching I am familiar, I would rate the as follows (check appropriate boxes below):
 
 
 

Criterion	Best	Upper  10%	Upper  25%	Above  Average	Below  Average
Quality of the material  presented in the course(s)
Ability to inspire students to do their best, to stretch
Impact of this instructor on my career development
Skill in helping students (availability, demeanor, etc.)
Strength of charactor
Contributions toward preparing students for life

Additional remarks (or letter of support):