LARRY DORE MEMBER OF THE YEAR AWARD ENTRY FORM
I. NOMINATOR/SPONSOR INFORMATION
Your Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Number of Years as Auxiliary Member
*
II. MEMBER BEING NOMINATED INFORMATION
Full Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
*
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Number of Years as Auxiliary Member
*
State/Local Auxiliary (if applicable)
List Offices Held in the Auxiliary and Community within the Past Three (3) Years (include name of office, name of organization, and year(s) office held)
List Nominee's Efforts in the Name of the Auxiliary at the Local, State, and National Levels
List Involvement in the Community (non-profit activity, special event planning, or other demonstrations of community involvement) During the Past Three Years
III. ESSAY
Provide a Convincing Essay (maximum of 500 words) Describing the Reason(s) the Nominee Should Be Selected as the Larry Dore Member of the Year
*
IV. SIGNATURE
I hereby certify that the above is true and accurate.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Upload supporting documents tracing back three years to validate achievements(examples are photos, newspaper articles, thank you letters, award notifications, etc.)
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