2010 DVGBC Annual Leadership Award Nominee Application Form

Nominator's First Name: *

Nominator's Last Name: *

Nominator's Title:

Nominator's Company:

Nominator's Address:

Nominator's City:

Nominator's State:

Nominator's Zip:

Nominator's Phone:

Nominator's E-mail: *

Who are you Nominating?:

If you chose other please explain here. :

Nominee First Name: *

Nominee Last Name: *

Nominee Title:

Nominee Company:

Nominee Address:

Nominee State:

Nominee Zip:

Nominee Phone:

Nominee E-mail: *

Description of Actions: *

Description of Action(s): Provide a summary of the initiative, action, or series of activities that was undertaken by the nominee to make him or her deserving of the DVGBC Leadership Award. Also, include whether this activity was innovative for the region or the organization/group with which the nominee is affiliated.

Nominee Role: *

Nominee Role: Describe the Nominee's role in the Action(s) you described above. Include how the Nominee displayed leadership and collaboration.

Benefit: *

Benefit: Explain the benefits that have been achieved through the action(s) you described above. Include both quantitative and qualitative information, when relevant, to illustrate the environmental, economic and or social impact of the action(s) taken.

Multiplier Effect: *

Multiplier Effect: Describe how the action(s) of the Nominee have influenced others or resulted in a broad impact beyond the immediate organization/activity.

Interest: *

Interest: Detail the length of time the Nominee has championed this activityor related work, how and when s/he first became interested in this area, and what inspired him/her to take action.

Additional Information:

Pleasse provide any additional information here.

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