Online Nomination Form

Thank you for nominating. We have allocated space for you to nominate up to 10 of your outstanding students in the 9^th through 12^th grades. Please provide the information required below. If you have any questions regarding the nomination process, contact us via our special educator-only e-mail address mededucator@nylf.org.

Educator / Mentor Information

Prefix:*

First Name:*

Last Name:*

E-mail:*

(Why is this required?)

Institution (or School Name):*

Preferred Phone:*

Institution Fax:*

There are times when NYLF seeks faculty advisors for its programs. Check here if you would be interested in serving.

Educator/Mentor Identification

I have received an invitation to nominate. I am submitting my Nominator ID below.

I am using another educator/mentor's invitation to nominate. I am submitting his/her Nominator ID below.

I did not receive an invitation to nominate and do not have a Nominator ID. (Go directly to "Nominee One " below.)

Nominator ID:

Nominee One (Required)

First Name:*

Last Name:*

Address 1:*

Address 2:

City:*

State:*

Zip Code:*

Gender:*

Grade in 2011/2012 Academic Year:*

Nominee Two

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

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Gender:

Grade in 2011/2012 Academic Year:

Nominee Three

First Name:

Last Name:

Address 1:

Address 2:

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Grade in 2011/2012 Academic Year:

Nominee Four

First Name:

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Address 1:

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Grade in 2011/2012 Academic Year:

Nominee Five

First Name:

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Address 1:

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Nominee Six

First Name:

Last Name:

Address 1:

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Grade in 2011/2012 Academic Year:

Nominee Seven

First Name:

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Address 1:

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Nominee Eight

First Name:

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Address 1:

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Grade in 2011/2012 Academic Year:

Nominee Nine

First Name:

Last Name:

Address 1:

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Grade in 2011/2012 Academic Year:

Nominee Ten

First Name:

Last Name:

Address 1:

Address 2:

City:

State:

Zip Code:

Gender:

Grade in 2011/2012 Academic Year:

Submit Your Nominations

By submitting, I agree that NYLF may contact me by e-mail, fax or phone with any questions about my student nominations.

*Indicates required field.