Name of nominee individual, business, organization or group)
Contact person if school, business, organization or group:
Contact person's e-mail address
Contact person's address:
Nominee's address:
Contact person's telephone number:
Nominee's telephone number:
Award category:
Please attach information describing the overall goals and objectives of the activity/program. Indicate the following:
a) Population directly affected. b) Length of time involved in project or program. c) If a specific activity, will it continue on a long term basis or does the project have a specific completion date? d) Additional reasons why this individual or organization should be selected.
a) Population directly affected.
b) Length of time involved in project or program.
c) If a specific activity, will it continue on a long term basis or does the project have a specific completion date?
d) Additional reasons why this individual or organization should be selected.
Please attach/forward any additional information which details the achievements and contributions of the nominee, including measurable results, audiovisuals and program materials. Submitted materials may not be returned.
