Form 1 Nomination Form

Chairman’s Commendation Circle Award
Nomination Form

Nominator’s Information

Name:
Organization:
Address:

Telephone:
E-mail:

Nominee’s Information
If you are nominating a business or organization, please identify the person
instrumental in bringing about this contribution or achievement.
Name:
Organization:
Address:

Telephone:
E-mail:

Please include details of how the individual has contributed to improving
consumer product safety, including:
 Nomination form cover page
 One (1) page (maximum) description of the individual or organization
 Two (2) page (maximum) description of how, and to what extent, the
nominee has contributed to improving consumer product safety
 One (1) page (maximum) summary of any additional information that
should be considered by the panel, including any grants received or
other recognition of the nominee’s achievements in the area of product
safety
 Up to three (3) letters of support or three (3) pages maximum of other
supporting documents

Signed: ___________________________ Date: _______________________

Once completed, please return the nomination form and supporting materials to:
Chairman’s Commendation Circle Award
U.S. Consumer Product Safety Commission
4330 East West Highway, Suite 724
Bethesda, MD 20814
Applications also can be submitted by e-mail to
[email protected] or by fax to (301) 504-0768.

PRIVACY ACT NOTICE
Authority: 15 U.S.C. § 2051(b). Purpose: The information being provided will assist the Chairman of the CPSC in selecting nominees for the
Chairman’s Commendation Circle Award Program. Other Uses: The information provided will not be otherwise disclosed outside of the CPSC,
except as permitted or required by law. Penalty: The information requested on this form and pursuant to this program is to be provided
voluntarily. There is no legal requirement to provide any information. Failure to provide any of the requested information may result in
disqualification for consideration for the subject award.