Cincinnati's Black Lifestyle - Applause! Magazine Online

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"Reach For The Stars"
NOMINATION FORM 2004
 

Nominee Information Section:

First Name: 
Middle Name: 
Last Name: 
Occupation: 
Title: 
Age: 
Nominee Contact Information Section:

Street: 
City: 
State: 
Zip: 
Home Phone: 
E-mail: 
Fax #: 
Nominee Company Information Section:

Company/organization: 
Company Address: 
City: 
State: 
Zip: 

 

What is the ethnic/cultural background of the nominee?

Category of Accomplishment 

Advocacy Education Public Service
Arts Entertainment Research/Technology
Communication Entrepreneurship Sports
Corporate Achievement Medicine/Health

Respond to the following statements. In order for this application to be considered, strict adherence to the format is required
and no attachments will be considered. The nomination cannot exceed two pages. Thank You.

  1. Describe the contributions of the nominee within the selected category.

  2. Provide biographical information on the nominee.

  3. Describe how the nominee has served as a role model for others.

  4. List the nominee's honors and awards.

  5. List the nominee's professional, civic and social organizational affiliations.

 

This section must be completed by the nominator.

First Name:  Last Name:
Middle Name
Address:  City:
State:  Zip:
Home Phone:  Business  Phone:
Fax #:  E-mail:

What is your relationship to the nominee?