Silver and Gold Circle Nomination Form

Silver and Gold Circle Nomination Form
Nominating for: *
Name of Nominee:*

First NameLast Name
Current Occupation/Organization:*
Nominee Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Nominee E-mail*
Date of First Employment in Television:*

MonthDayYear
Place of First Employment in Television:*
Summary of Employment in Television:
Starting Year:*
Ending Year:
Please State Significant Contributions to Regional Television and your Market:*
Please State the Emmy Awards received and the year they were received:*
Detail your specific involvement with the chapter and the dates you served (Example: Emmy Awards volunteer 2012-2016, board member 1995-1997):*
Please State any other awards received (Press Club, SPJ, etc):*
Detail your specific community involvement and the dates you served (Example: Boys and Girls Club volunteer 2010-2015):*
Places of Employment in Television:

A significant portion of the candidate's career should be within the Pacific Southwest Region, which is comprised of the San Diego, Bakersfield, Las Vegas, Palm Springs, San Luis Obispo, Santa Barbara, and Santa Maria markets.
Name of Organization*
Starting Year:*
Ending Year:*
Name of Organization*
Starting Year:*
Ending Year:*
Name of Organization
Starting Year:
Ending Year:
Name of Organization
Starting Year:
Ending Year:
Name of Organization
Starting Year:
Ending Year:
Name of Organization
Starting Year:
Ending Year:
Name of Organization
Starting Year:
Ending Year:
Name of Organization
Starting Year:
Ending Year:
Name of Organization
Starting Year:
Ending Year:
Name of Organization
Starting Year:
Ending Year:
Submitter's Information
Submitted by:*
Do you wish your nomination remain confidential?*
Company Name:*
Company Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Your E-mail*
Enter the message as it's shown*
Should be Empty:

Silver and Gold Circle Nomination Form

Submitter's Information