About the Nominee

* Required Field

Name: *

Mailing Address: *

Phone Number: *

Organization where volunteer service was performed (and position, if applicable):
(Paid employees are not eligible for consideration unless service is well above and beyond the description of their regular duties.)

Description of nominated service: * (Describe in detail the service you feel is noteworthy)

Period of Service: * (Need not be limited to month nominated.)

Volunteer Hours: (If recorded)

Related or Other Volunteer Service: (List actions or endeavors that show a pattern of volunteerism. This program recognizes individuals who routinely "give back" to their communities.)

Other pertinent information: (Any other information you feel strengthens your nomination and introduces your nominee.)

Place of work and job title (if applicable):

About the person submitting the nomination

Name: *

Title:

Organization:

Phone Number:

Email Address: *

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