Recognition Nomination Form
Nominate an individual whose leadership, service, achievement, character, and community impact deserve meaningful recognition.
Nominator Information
Full Name
*
First Name
Middle Name
Last Name
Organization (if applicable)
Title
Email Address
*
example@example.com
Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to the Nominee
*
Family Member
Friend
Colleague
Church Leader
Employer or Supervisor
Neighbor
Mentor
Teacher
Other
Nominee Information
Nominee’s Full Name
*
First Name
Middle Name
Last Name
Preferred Name (if different)
Current Position or Occupation
*
Organization, Church, Ministry, or Business
City & State
*
Telephone Number (if known)
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (if known)
example@example.com
Recognition and Supporting Details
Recognition Category
*
Honorary Doctorate in Humanitarianism
Distinguished Leadership Recognition
Excellence and Service Award
Tall One Champion Award
Humanitarian & Community Service Recognition
Other
Getting to Know the Nominee – Has the nominee (check all that apply)
Demonstrated outstanding leadership
Made a significant impact in the community
Served others through volunteer or humanitarian work
Founded a ministry/nonprofit/business/community program
Mentored or developed others
Exhibited integrity and character
Inspired positive change in others
Overcame significant challenges
Advanced education, health, or social outcomes
Shown sustained commitment over time
Why does this individual deserve recognition?
*
Supporting Information (check any items submitted)
Biography
Résumé or Curriculum Vitae
Letter of Recommendation
Professional Photograph
Awards or Certificates
Press Coverage or Articles
Program Brochure or Flyer
Video or Media Links
Other Supporting Documents
Other
Reference and Certification
Reference Name
*
First Name
Middle Name
Last Name
Reference Title
Reference Organization
Reference Telephone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Reference Email Address
*
example@example.com
Certification
*
I certify that the information provided is accurate to the best of my knowledge.
I understand that the Summerville Institute for Excellence & Service may verify the information provided.
I understand that submitting a nomination does not guarantee selection.
I understand that the Institute reserves the right to determine the most appropriate recognition category.
Electronic Signature
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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