Top
of Form
Please
complete all fields. Incomplete nominations will not be
accepted.
Nominee's
Information
First
Name:
|
|
Last
Name:
|
|
Home
Address:
|
|
City:
|
|
State:
|
|
Zip:
|
|
Daytime
Telephone:
|
|
Fax:
|
|
Evening
Telephone:
|
|
|
|
|
|
Email:
|
|
|
|
Program:
|
|
|
|
Please
select "AmeriCorps Alumni" if individual completed
service in either AmeriCorps, AmeriCorps*VISTA, or
AmeriCorps*NCCC by January 15, 2006.
|
Service
Dates:
|
|
|
|
Nominator's
Information
First
Name:
|
|
Last
Name:
|
|
Home
Address:
|
|
City:
|
|
State:
|
|
Zip:
|
|
Daytime
Telephone:
|
|
Fax:
|
|
Evening
Telephone:
|
|
|
|
|
|
Email:
|
|
|
|
|
|
|
|
In
250 words or less, Tell us about the person you are
nominating. Where is this person serving currently? What
are this person’s service responsibilities? When did
he or she start serving? What qualities set this person
apart from other individuals who serve in your program?
|
In
250 words or less, Tell us about the leadership qualities of
the person you are nominating. How has this person inspired
others and encouraged others to serve? Has he or she taken
on particular leadership roles in your organization or in the
community that set them apart? If so, please describe these
roles.
In
250 words or less, Provide some examples of tangible outcomes
the person you are nominating has achieved. For instance,
discuss problems solved, measurable changes (like test
scores, truancy rates, changes in rates of infection,
mentoring matches, etc.), dollars saved, effective leveraging
of volunteers and resources, number of people served. Please
be as specific as possible and identify some examples of the
impact this individual has made.
In
250 words or less, Tell us about the extraordinary efforts
made by the person you are nominating. Has this person had
to overcome any personal challenges? Has this person’s
service changed your programming, capacity for service
delivery or sustainability in any way? What makes this
person’s efforts stand out from others?
|
|
Privacy
Policy:
You are advised that a nominee's name, as well as all submission
material, may be used for news or publicity programs connected
with the Corporation for National and Community Service
(Corporation). Contact information, however, will not be shared
with anyone outside the Corporation, and only with individuals
within the Corporation who have an official need to know the
information. Finally, if a nominee or nominator does not want his
or her name and / or narrative information used for purposes of
news, publicity, or publications, please indicate this within
your submission.
OMB
Document Numbers:
3045-XXXX
Bottom
of Form
|