National Award Nomination Application

O MB Control # 1093-0004
Expires XX/XX/2013

National Award Nomination Application

PART I: NOMINATION INFORMATION

1. Name of Nominated Individual or Organization/ Group:

__________________________________________________________________

*Name to be inscribed on award or certificate.

Please select the category that most closely identifies your organization.

(Select only one - required)

____ Individual

____ School Program

____ Youth/ Youth Group

____ Corporation or Business

____ Non-Profit Organization

____ Faith Based Group

____ Federal Event/ Program

____ State Event/ Program

____ Local Government Event/ Program

____ Public/ Private Partnership

2. Nominee: Contact information for individual or organization being nominated

Name of individual or the contact person for organization/ group:

Title (if applicable):

Street Address:

City, State, Zip:

Phone:

Fax (optional):

Email:

For organizations or groups, in 100 words or less, please describe the organization or group and their mission.

Is the nominee aware of this nomination? ____ Yes ____ No

Note: Nominee must be aware of and consent to nomination.

3. Nomination Submitted by: (If you are nominating yourself, skip C and go to Part II)

Name:

Title (if applicable):

Organization (if applicable):

Street Address:

City, State, Zip:

Phone:

Fax (optional):

Email:

Relationship to Nominee:

PART II: PROJECT AND ACTIVITY INFORMATION

1. Site location and Ownership

Site Name:

Address:

City, State, Zip:

Phone Number:

Land Owner/ Manager (Check all that apply)

□ Federal □ State □ County

□ City □ Tribal □ Other; Please Specify: ________________

2. Is the project ongoing? ____ Yes ____No

If no, how long did event/ project last? ________ Days ________ Months

Did the activity occur between May 1, 2009 and April 30, 2010 _____ Yes ____ No

*If no, project or activity does not qualify for an award this year.

3. Type of Activity

Please select primary event/ project purpose. Select no more than three options.

____ Habitat Restoration

Example: Riparian/ Streamside; Plants (weeds, native plants); Wildlife; Range; Fish; Prairie; Forest; Wetland

____ Soil/ Water Conservation

____ Education/ Interpretation Outreach

____ Research/ Monitoring/ Studies

Example: Plants; Wildlife; Archaeological; Historic/ Cultural Fossils; Watershed; Soil; Minerals; Mapping; Toxins

____ Construction

Example: Trails/ Pathways; Fences; Signs

____ Species Management

Example: Fish; Wildlife; Horses and Burros

____ Historic/ Cultural Restoration Improvement

Example: Site; Structure

____ Clean-Up/ Maintenance

Example: “Adopt-a” effort; Grounds or Gardens; Trails

____ Host/ Site Steward/ Interpretation

Example: Campground Host; Park Guide; Visitor Information

____ Administration

Example: Data Entry; Office; Public Relations

____ Other; Please specify ____________________________________

4. Volunteer Information

Total number of event/ project volunteers: ______________________

Total event/ project hours for award year: ______________________

E. Community or Partner References

Please list three contacts, with phone numbers, who are familiar with the history and success of the event/ project.

Name: Organization: Phone:

Name: Organization: Phone:

Name: Organization: Phone:

PART III : PROJECT SUMMARY

1. Project Summary. Summarize the scope of the project/ activity. Please list no more than five major goals and resulting accomplishments. Quantify whenever possible (i.e. number of miles groomed, bags/lbs. of trash collected, etc.). Please limit your response to 5,000 characters (approximately two single-spaced pages).

2. Project Impact. Summarize the impact and benefits of this project/ activity on the event site, natural resources and/ or community. Please list no more than five major benefits/ impacts for the resulting beneficiaries. Quantify the impact whenever possible. Please limit your response to 2,500 characters (approximately one single-spaced page).

3. Project Partnerships. Briefly describe the collaborative or partnership efforts associated with this project/ activity. Please indicate any funding sources and/ or in-kind donations received for this project/ activity. Please limit your response to 2,500 characters (approximately one single-spaced page).

By submitting this application, the nominator attests that the application has been filled out to the best of their knowledge and that the individual or organization nominated has been informed and has agreed to the nomination.

 I Accept  I Decline ____ Initials

Privacy Act Statement

This information is being collected to further the purposes of the Take Pride in America Act (16 U.S.C. 4601 et seq.). Furnishing this information is voluntary. It will be used to select finalists and winners of Take Pride in America Awards, using an outside panel of judges, and for the public awareness campaign authorized by the Act. Information collected via this application is covered by the Privacy Act of 1974 (5 U.S.C. 552a) and Privacy Act System of Records Notice Interior OS-14: Take Pride in America System. Access to this information is limited to only those officers and employees of the Department of the Interior who have a need for the information in the performance of their duties. Disclosure without the consent of the subject of this information is restricted unless required by the Freedom of Information Act to those listed in the Notice under its “Routine Uses” section and to those identified in 43 CFR 2.56.

Paperwork Reduction Act Statement

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that this information is being used to select finalists and winners of Take Pride in America Awards. Response to this request is voluntary. The public reporting burden for this collection of information is estimated to average one hour per response, including the time required for gathering the data needed and completing and reviewing the collection of information form. Send comments on the burden estimate or on any other aspect of this collection of information, including suggestions for reducing this burden, to Department of the Interior, Executive Director, Take Pride in America, Room 3459, 1849 C Street N.W., Washington, D.C., 20240. Under the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.