The Potato Association of America
HONORARY LIFE MEMBERSHIP NOMINATION FORM

   NOMINEE'S NAME:
  ADDRESS:                                                                                                                                           
                                                                                                                                                              
                                                                                                                                                              
  PHONE:                                       FAX:                                     E-MAIL:                                             
  EDUCATION:                                                                                                                                        
                                                                                                                                                              
                                                                                                                                                              
                                                                                                                                                              
                                                                                                                                                              
                                                                                                                                                               
  CAREER HIGHLIGHTS:                                                                                                                    
                                                                                                                                                              
                                                                                                                                                              
                                                                                                                                                              
                                                                                                                                                              
                                                                                                                                                              
  PARTICIPATION IN THE POTATO ASSOCIATION OF AMERICA:                                                           
                                                                                                                                                              
                                                                                                                                                              
                                                                                                                                                              
                                                                                                                                                              


Nominator: [Please Print]                                                                                                                       

   Signed:                                                                                                                                                
   Address:                                                                                                                                              
                                                                                                                                                              
                                                                                                                                                              
   Nomination Supporters (5 including nominator: Include name, address, phone number & e-mail)
Name [Nominator] Address Phone No. & E-mail
 

 

    
 

 

    
 

 

    
 

 

    

Send to: Alexander D. Pavlista, Ph.D.
apavlista@unl.edu