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nomination form and information (paper)

just the nomination form (paper)

printable checklist

submit 500 word statement and supporting materials here

Deadline:
Postmarked, delivered, or submitted online by
April 12, 2013 at 5:00 p.m.


 
 


Governor's Service Awards
Nomination Form


Nominee's name:

Contact Name: (if nominee is an organization)


Age:

Years of Operation: (if nominee is an organization)


Address:
City:
State:
Zip:
County:
Phone Number:
Email Address:

Verification
Please list three (3) references who can verify the scope and extent of the nominee’s community service activities. This person should be familiar with the community service of the nominee and may not be the nominator, nominee or a relative of the nominee.

  Name Phone
Reference 1
Reference 2
Reference 3


Summary
Please provide a brief statement describing the nominee’s voluntary community service activity.


Nominator's Name:
Address:
City:
State:
Zip:
Phone Number:
Relationship to Nominee:
Email Address:

Category:
Youth (Ages 6-11)
Youth (Ages 12-14)
Youth (Ages 15-18)
Young Adult (Ages 19-30)
Adult (Ages 31-59)
Senior (60+)
National Service
Lifetime Achievement
Family
Organization
Business (less than 50 employees)
Business (more than 50 employees)


How will you send your supporting documents?
Postal Service
Hand Delivered
Online Submission

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