1. Entry Date

2. Entry Title (Please limit title to five words or fewer describing the innovation)

3. Name to appear on the Agency Award Plaque (Office/Team or Individual)

4. Contact Information. The person listed below has active responsibility for the development or implementation of this innovative policy or practice. All correspondence related to this entry will be directed to this individual.

Name:

Title:

Department/Agency:

Office/Service/Division:

Address:

City:

State:

Zip Code:

Telephone:

Fax:

Email:

5. Authorizing Official's Certification and Signature. Agency official sponsoring the nomination.

Name:

Title:

Department/Agency:

Office/Service/Division:

Authorizing Official's Signature:
Date:

Credits:

In addition to the person identified in item 4, above, list any other individuals or office/team members responsible for the project. If you need additional space, please type on white paper and attach it to the Entry Form.

Team member

Name:

Role/Title:

Department/Agency:

Office/Service/Division:

Address:

City:

State:

Zip Code:

Office Telephone:

Fax:

Team member

Name:

Role/Title:

Department/Agency:

Office/Service/Division:

Address:

City:

State:

Zip Code:

Office Telephone:

Fax:

Narrative Information:

Thank you for using our electronic award entry form.

If you have questions on completing this form, please send an email message with your comments to darlene.stickel@gsa.gov.

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