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201 I Mayor's Community Volunteer of the Month Award <br />Official Nomination Form <br />Nominee: Indicate Mr., Mrs., Ms., Miss <br />Name: <br />Address: <br />City: <br />Daytime Phone Number: <br />~'imoil ora~racr <br />Please check the appropriate age classification for your nominee: <br />^ Youth (18 and under) ^ Young Adult (19-25) ^ Adult <br />^ Senior (55 and over) ^ Group <br />Verification: To qualify, the nominee must have one reference who may be contacted to verify the scope and extent <br />of the nominee's activities. Reference should be a person familiar with the community service activities for which <br />the nomination is made and should not include either the nominee or any persons related to the nominee. The <br />reference below must be someone other than the nominator. <br />Reference: <br />Name: <br />Daytime Phone Number: <br />Address: <br />City: <br />Agency/Organization: <br />Nominator: <br />Name: <br />Daytime Phone Number: <br />Address: <br />City: <br />Agency/Organization: <br />Signature: <br />State: Zip: <br />State: <br />Zip: <br />State: <br />Zip: <br />n:\public bodies\ciry councfl\council\mayox\dietz\mayor s volunteer of the month awaxd.docx <br />