Form
Individual Awards Nomination
Award Selection
Please Select
Youth
Adult
Senior
AmeriCorps
AmeriCorps Senior
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Nominee Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Phone Number
Please enter a valid phone number.
Email
example@example.com
Date of Birth
xx/xx/xxxx
Service Location(s) Information
Name of organizations
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Organization/Community
Served
Organization/Community
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Phone Number
Please enter a valid phone number.
Email
example@example.com
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Nominator Information
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County
Phone Number
Please enter a valid phone number.
Email
example@example.com
Relationship to Nominee
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Category
Was the Nominee an AmeriCorps Member
Yes
No
If so, Check which
NCCC
VISTA
State
National
Was the nominee an AmeriCorps Seniors (Senior Corps) Volunteer
Yes
No
If so, Check which
RSVP
SCP
FGP
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Narratives
Please answer the following questions in 400 words or less per answer
Volunteer activity (ies): What volunteer service did the nominee provide? When was it provided? What community need did the volunteerism address? Was the volunteer part of a group? Did the volunteer lead the group?
Impact: What was the impact of the nominee's service? How did the community/organization benefit from the nominee's service?
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