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Loyola Medal - Nomination form

This is information about you, the nominator, so we can contact you with any questions.

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* Email

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* First name

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* Last name

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* Concordia degree and year (if applicable)

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* Concordia title (if you are faculty/staff)

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* Address line 1

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* Address line 2

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* City

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* Province/State

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* Postal/Zip Code

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* Country