BLACK ACHIEVERS NOMINATION FORM

BLACK ACHIEVERS SOCIETY AWARD NOMINATION FORM
Black Achievers Society Mission

To actively respond to the educational, social, and economic needs of the community by providing role models for Blacks and minority youth, sharing knowledge gained through academic and corporate experiences.

Thank you for considering a nominee for the Black Achievers award. Please complete all sections below along with submitting your information via the Nominator Contact form below. It is highly recommended that the nominee has consented to the nomination prior to submitting this form.

Please Note:

Nominations should be submitted on behalf of the nominee’s sponsoring company (employer). Entrepreneurs may self-nominate as the executive leader of their business.
Candidate Name*
Company*
Current Title*
Executive Leadership (C-Suite)Senior Leadership (Vice President/Senior Vice President)Mid-Level Leadership (Supervisor/Manager/Director)Individual Contributor (Business Owner/Entrepreneur)
Contact Telephone*
Format: (000) 000-0000.
Work Email Address*
example@example.com
Alternate Email Address
example@example.com
High School/GEDTrade, Technical, Vocational or Military SchoolAssociate DegreeBachelor DegreeMaster DegreeDoctorate Degree
Years of Service with Company*
Total Years of Experience*
BLACK ACHIEVERS SOCIETY CANDIDATE INFORMATION
Please provide a thorough response for each section. Be sure to include details and examples. Nominators are encouraged to gather information prior to completing the form.
CORPORATE LEADERSHIP - Give an objective overview of the candidate's current position and its relative importance to the organization. *
COMMUNITY ACTIVITIES/LEADERSHIP - Provide a diverse list of the candidate's activities contributing to the betterment of the community, outside of company sponsored service work. Include specifics concerning the depth of involvement in each activity. Limit examples of community leadership activities that have occurred over the past 3 years. *
EDUCATIONAL ACHIEVEMENT - List candidate's academic achievements (degrees, awards, honors). Include examples of the candidate sharing his/her academic expertise in areas external to immediate corporate environment. *
CORPORATE ACHIEVEMENT - Give an objective overview of previous leadership positions, achievements and awards the candidate has received within the organization and length of service in present position. *
CORPORATE STATEMENT - Is the nominee considered a leader, role model, or mentor for other employees in the organization? How does this prospective honoree understand and embrace your company's values and leadership competencies?*
FAMILY STATUS - Please indicate family demographics if applicable (martial status, children, etc.).*
BLACK ACHIEVERS SOCIETY AWARD NOMINATOR CONTACT FORM
Please complete each field as indicated with the red asterisk. This information will be used for communication purposes for the award ceremony should the nominee be selected.
I am interested in learning more about sponsorship opportunitiesI am interested in supporting my nominee as a sponsorI am a current sponsorI only wish to purchase tickets for the awards dinner
Company Name*
Company Contact Name*
Title*
Address*

Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Telephone*
Format: (000) 000-0000.
Fax
Email Address*
example@example.com
Alternate Company Contact*
Telephone*
Format: (000) 000-0000.
Title*
Email Address*
example@example.com
Awards Dinner RSVP/Ticket purchase Contact*
Telephone
Format: (000) 000-0000.
Email Address
example@example.com
Should be Empty:

BLACK ACHIEVERS SOCIETY AWARD NOMINATION FORM

BLACK ACHIEVERS SOCIETY CANDIDATE INFORMATION

BLACK ACHIEVERS SOCIETY AWARD NOMINATOR CONTACT FORM