Nominate a Volunteer

Full Name of Individual Nominated:

Street Address:

City:

State:

Zip:

E-Mail Address:

Home Phone:

Work Phone:

Full Name of Individual Nominator:

Street Address:

City:

State:

Zip:

E-Mail Address:

Home Phone:

Work Phone:

The following sentence needs to be completed. Please limit your essay to 300 words.

Remember to include: Names and contact numbers for references who can verify or give additional information on the individual's activities.
The deadline for nominations is February 18th, 2013.

This individual is nominated for the 2013 Jefferson Awards because...

Security Code: