NationalService.gov > Submission Form

First Name:	Last Name:
Home Address:
City:	State:	Zip:
Daytime Telephone:	Fax:
Evening Telephone:
Email:

In 250 words or less, Tell us about the person you are nominating. Where is this person serving currently? What are this person’s service responsibilities? When did he or she start serving? What qualities set this person apart from other individuals who serve in your program?



In 250 words or less, Tell us about the leadership qualities of the person you are nominating. How has this person inspired others and encouraged others to serve? Has he or she taken on particular leadership roles in your organization or in the community that set them apart? If so, please describe these roles.



In 250 words or less, Provide some examples of tangible outcomes the person you are nominating has achieved. For instance, discuss problems solved, measurable changes (like test scores, truancy rates, changes in rates of infection, mentoring matches, etc.), dollars saved, effective leveraging of volunteers and resources, number of people served. Please be as specific as possible and identify some examples of the impact this individual has made.



In 250 words or less, Tell us about the extraordinary efforts made by the person you are nominating. Has this person had to overcome any personal challenges? Has this person’s service changed your programming, capacity for service delivery or sustainability in any way? What makes this person’s efforts stand out from others?

Privacy Policy: You are advised that a nominee's name, as well as all submission material, may be used for news or publicity programs connected with the Corporation for National and Community Service (Corporation). Contact information, however, will not be shared with anyone outside the Corporation, and only with individuals within the Corporation who have an official need to know the information. Finally, if a nominee or nominator does not want his or her name and / or narrative information used for purposes of news, publicity, or publications, please indicate this within your submission.

OMB Document Numbers:
Senior Corps: 3045-0091, AmeriCorps: 3045-0092, Learn & Serve America: 3045-0093, Corporate: 3045-0115