Nominee:

Office:

Telephone: Day

Give a brief description of the nominee's job position and duties:

Summarize the Nominee's outstanding service and/or achievements:

Provide a detailed explanation of how the Nominee's significant singular contribution or his or her outstanding service to the profession has benefited the public or a governmental entity:

List any other factor(s) that you believe would assist the Awards Committee in evaluating the nomination:

Provide the name, title, and telephone number of three individuals who are familiar with the Nominee's achievements. Also include the name and telephone number of the head of the Nominee's office or his or her supervisor.