Centurions Nomination Form

Centurions Nomination Form
How to Join

If you are interested in serving on the Chancellor’s Centurions or would like to nominate someone you know, please complete the form below. Once submitted, the nominee will be contacted to complete the membership process.
Date*

MonthDayYear
Date
Your name*

First NameLast Name
Your email*
Your cell phone number *
Nominee's Biographical Information
Nominee's name*

First NameLast Name
Spouse's name, if applicable

First NameLast Name
Home Mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell number
Nominee's Educational Information
Please include university name(s), degree(s) received, and class year(s)
Nominee's Affiliations and Volunteer Engagement at UT Institutions
Please select all that apply

UT ArlingtonUT AustinUT DallasUT El PasoUT Permian BasinUT Rio Grande ValleyUT San AntonioUT TylerUT Southwestern Medical CenterUT Medical Branch at GalvestonUT Health Science Center at HoustonUT Health Science Center at San AntonioUT MD Anderson Cancer CenterStephen F. Austin State UniversityUT System Administration
Other biographical, community, or business information
*We request that members attend a minimum of one event per UT System fiscal year. Additionally, we require a minimum annual financial contribution of $500.00 from each member. Please reference the Chancellor's Centurions By-laws here.

We take your privacy seriously and will not use the information you provide for purposes other than those needed to contact you about participation on the Centurions and provide information and updates about our program.

Please contact Melissa Jackson with any questions you may have about joining the Chancellor's Centurions.
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Centurions Nomination Form

Nominee's Biographical Information

Nominee's Educational Information

Nominee's Affiliations and Volunteer Engagement at UT Institutions