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Jefferson Awards Nomination Form
Step 1: Nominee Information
First name:
Last Name:
Email address:
Address 1:
Address 2:
State:
Zip code:
Home phone:
Work phone:
Local media partner:
Step 2: Nominator Information
First name:
Last Name:
Email address:
Address 1:
Address 2:
State:
Zip code:
Home phone:
Work phone:
Relationship: Describe your relation to the nominee, including how long you have known him/her.
References: List two additional people who are not related to the nominee as references. Please include phone numbers.
Outstanding Personal Acts: Please describe the nominee's outstanding personal acts.


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