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Nomination Deadline is August 1st, 2009.

 
If you have difficulty with this nomination form, please email sharon@jaindy.org for assistance.
General information

 
Candidate information
Name:
Mailing Address:
City:
State:
Zip:
E-mail:
Business Phone:
Title:
Company:
Biographical information
Age:
Birth date:  (Example: 07/09/64)
Educational background
College/Univ.:
Degree:  (AS, BS, Other)
List advance degrees, institution(s) and degree field(s) 
Employment/Community Involvement
1. Describe one or two of the candidate's greatest professional accomplishments.
2. Describe the leadership qualities the candidate has demonstrated in the work place or in the community, or both.
3. How has the candidate's character positively affected the workplace or community, or both?
4. Has the candidate been convicted of a felony?
(Please note "conviction" includes a plea, verdict, or finding of guilty regardless of whether the court sentenced them.)
 .
   
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If yes, please explain:
5. Is the candidate currently awaiting trial for a felony or misdemeanor?
 .
   
.

If yes, please explain:

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Nominator information
Name:
Title:
Company:
Email:
Address:
City:
State:    Zip: 
Business phone: Area Code
  

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