Deadline for entries has been extended to Friday, July 31, 2009.

Please limit your nomination to 300 words. All parts of your nomination must be complete for judges to review.

Your description should be as specific as possible. Please include:

• The name of the organization(s) for which your nominee volunteers.
• The number of hours your nominee volunteers each month.
• A description of how his or her efforts impact the community.
• A short story that demonstrates the character and qualities of the individual and his or her volunteer efforts.
• If available, a link to the website of the organization for which your nominee volunteers.

I nominate the following as a Jefferson Awards Nominee:

Name *

Address *

City *, State *, Zip *

Telephone (daytime) *

Telephone (evening)

Age Range *
-- Choose -- Under 25 26-40 41-55 56-65 66+ Family

Contact to verify the accuracy of the nomination information:

Non-profit organization *

Name of contact person *

Name of Executive Director *

Address *

City *, State *, Zip *

Website address

Telephone *

Please complete the following about yourself:

Name *

Address *

City *, State *, Zip *

Telephone (daytime) *

Telephone (evening)

Email *

Relation to nominee *
-- Choose -- Volunteer coordinator Board member or director Fellow volunteer Friend Family/relative Spouse Co-worker Neighbor Other - explain

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