Old Mill Local Hero Program Nomination Form

Old Mill Hero Program Nomination Form

Nominate a local veteran in need of home accessibility improvements. Nominations open May 1st–June 30th. Recipient announced the first week of July.
Nominee (Veteran) Information
Nominee Name
Nominee Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Nominee Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Nominee Email
example@example.com
Is the nominee a local veteran? Please specify branch and years of service.
Accessibility Needs & Project Details
Description of accessibility needs (What part of the home? What are the current barriers?)
Requested improvement (Accessible room modification or accessible entrance)
Reason for Nomination
Why does this nominee deserve to be selected as our Local Hero Recipient?
Nominator Information
Nominator Name
Nominator Relationship to Nominee
Nominator Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Nominator Email
example@example.com
Preferred contact method
Confirmation & Permissions
I confirm the nominee is aware of and agrees to this nomination.
Additional Information
Additional comments or information
Should be Empty:

Old Mill Hero Program Nomination Form