O
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Control # 1093-0004
Expires XX/XX/2013
National Award Nomination Application
PART I: NOMINATION INFORMATION
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
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.
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
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: ________________
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.
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 ____________________________________
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
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).
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).
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.
File Type | application/msword |
File Title | 2006 National Awards Nomination |
Author | Lisa Young |
Last Modified By | Rachel Drucker |
File Modified | 2010-03-17 |
File Created | 2010-03-17 |