Mesa's Man & Woman of the Year
Nomination Form
(please print or type)                  

Name of Nominee: ____________________________________________________

Home Address: ______________________________________________________

Evening phone: _____________          Daytime phone: _____________________

Occupation:_________________         Cell phone: __________________________

E-mail Address:________________________________ ______________________

This nomination submitted by:

Name: ______________________________  Evening phone: __________________

Address:_____________________________________________________________

Cell phone: ________________________    Daytime phone: __________________

E-mail Address:_______________________________________________________

Narrative: Using the criteria for this award, please provide a narrative explaining why this nominee should be considered for the award.  Please explain, with specific examples, how the nominee has distinguished him/herself through significant accomplishments in volunteer service. Please include names of  organizations, years of service, leadership roles, honors, awards and noteworthy service contributions.

Please attach your narrative with this Nomination Form.  If you wish to do so, please enclose any letters of endorsement you might have as well.

Would you like to make a short oral presentation to the Selection Committee on Friday, December 7, 2012?   Yes_______    No ______    A member of the Selection Committee may contact you for clarification or further information about your nominee.

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