About the Nominee:

Nominee's Name:

Nominee's Title:

Nominee's Email:

Nominee's Business:

Nominee's Address:

Nominee's City:

Nominee's State:

  Nominee's Zip:

Nominee's Phone:

Nominee's Fax:

1. Describe, as best you can, the nominees business accomplishments:

2. Describe, as best you can, some examples of the nominee’s community leadership / involvement:

3. The nominee has demonstrated the following qualities (check all that apply and explain in the memo field below):

Business Excellence
Courageous Thinking
Vision Innovation
Inspiring Leadership
Role Model

4. Please provide us with the names/addresses/phone numbers of other community leaders who know the nominee and can provide additional information.

Nominated by:

Your Name:

Your Title:

Your Email:

Your Business:

Your Address:

Your City:

Your State:

  Your Zip:

Your Phone:

Your Fax: