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Request for Campus Memorial Plaque

Requestor's Name ________________________________________________________

Address ________________________________________________________________
                 Street                                                           City                                       State                          Zip

Phone (work) _________________________ (home) ____________________________

Name of Honoree (as you wish it to appear) ____________________________________

__________________________________________                        _________________
Requestor's Signature                                                                           Date

Please make check for $25 payable to the CNM Foundation Campus Memorial Fund.

Submit form to:                                                 Or fax to:

Communication Officer,                                    505-224-4417
CNM Public Information Office
525 Buena Vista SE
Albuquerque, NM  87106