MBDA National Minority Enterprise Awards

MINORITY ENTERPRISE DEVELOPMENT (MED) WEEK

AWARD NOMINATION FORM

I. NOMINEE’S INFORMATION

Name/Title of Nominee: ________________________________________________________________________

Street Address of Business: _____________________________________________________________________

City, State, Zip Code: __________________________________________________________________________

Nominee Contact Person: _______________________________________________________________________

Email Address of Nominee: _____________________________________________________________________

Telephone No.: ________________________________________________________________________________

Web Address: _________________________________________________________________________________

Type of Organization/Business (Brief description) ___________________________________________________

II. NOMINATOR’S INFORMATION

Nominator’s Name: ____________________________________________________________________________

Title: ________________________________________________________________________________________

Organization/Business: _________________________________________________________________________

Street Address:_________________________________________________________________________________

Telephone No: ________________________________________________________________________________

E-mail Address: ______________________________________________________________________________

III. NOMINATION:

Award Category: ______________________________________________________________________________

Sub-Category: ________________________________________________________________________________

Explain why the nominee is deserving of the award for which you are nominating them. Note, in particular how the nominee meets the criteria for the award as laid out in the Call for Nominations brochure. Be as specific as possible. (Please note that MBDA may make this information publicly available. Please do not include any confidential business information.)

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________________________________________________

CERTIFICATION

I certify that to the best of my knowledge that the substantive statements in this application are true and accurate.

Nominator’s Signature and Date _______________________________________________________

Public Burden Statement

An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number (0640-0025). Public reporting burden for this report is estimated to average no extra burden per response. This burden includes time for reviewing instructions, searching existing

data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to:

Minority Business Development Agency

U.S. Department of Commerce

1401 Constitution Ave NW

Washington, DC 20230

The OMB Control Number for this collection is 0640-0025; Expiration Date: XX/XX/2027