Laserfiche WebLink
<br />2015 City of Elk River Sustainable Community Award <br />Official Nomination Form <br /> <br />Nominee: Indicate Mr., Mrs., Ms., Miss Today’s Date: _________________________ <br /> <br />Applications are valid from 6 months from the time of submission <br /> <br />Name: ________________________________________________________________________________ <br /> <br />Address: _______________________________________________________________________________ <br /> <br />City: _________________________________________ State: ___________ Zip: ____________________ <br /> <br />Daytime Phone Number: __________________________________________________________________ <br /> <br />Email address: __________________________________________________________________________ <br /> <br />Please check the appropriate age classification for your nominee: <br /> <br /> <br /> Youth (18 and under) Young Adult (19-25) Adult <br /> <br /> <br /> Senior (55 and over) Group <br /> <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 /> <br />Reference: <br />Name: _______________________________________________________________________________ <br /> <br />Daytime Phone Number: _________________________________________________________________ <br /> <br />Address: ______________________________________________________________________________ <br /> <br />City: _______________________________________ State: ___________ Zip: _____________________ <br /> <br />Agency/Organization: ___________________________________________________________________ <br /> <br />Nominator: <br />Name: ________________________________________________________________________________ <br /> <br />Daytime Phone Number: _________________________________________________________________ <br /> <br />Address: ______________________________________________________________________________ <br /> <br />City: ______________________________________ State: ___________ Zip: ______________________ <br /> <br />Agency/Organization: ___________________________________________________________________ <br /> <br />Signature: _____________________________________________________________________________ <br />n:\public bodies\agenda packets\05-04-2015\final\x4.10 at1 mayors sustainability award of the month - final.docx <br />