Form
Business Excellence Award Nomination
Award Selection
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Business Excellence Service Award
The organizations for which volunteers provide services may include entities exempt from federal income tax under Section 501(c) of the Internal Revenue Code of 1986, as amended. Missouri statute, § 105.1500,RSMo, prohibits state agencies from: (1) requiring an individual to provide data that directly or indirectly identifies a person as a member, supporter, or volunteer of a 501(c) entity (“personal information”); and (2) requiring a501(c) entity to provide data that directly or indirectly identifies a personas a member, supporter, or volunteer of that 501(c) entity (also, “personal information”). Nominator understands and represents that it is voluntarily providing information, which may include “personal information,” to the Missouri Community Service Commission (“MCSC”), and the state department to which it is assigned by law, the Department of Economic Development (“DED”),their employees and officials, in order for a nominee to be considered for the Show Me Service Volunteer Awards. Nominator hereby waives any right it may have under § 105.1500, RSMo,to claim that MCSC, DED, and their employees or officials are compelling Nominator to release any personal information by completing and submitting this Nomination Form.
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Business 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.
Format: (000) 000-0000.
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.
Format: (000) 000-0000.
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.
Format: (000) 000-0000.
Email
example@example.com
Relationship to Business
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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 organization provide? When was it provided? What community need did the volunteerism address? How many employees were involved in the service project?
Impact: What was the impact of the service project? How did the community/ organization benefit from the service project?
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