KCWY13 - NBC For Wyoming - Jefferson Awards for Public Service

Please fill out the form below to nominate your candidate or, if you prefer, mail us your type written nomination to Jefferson Award, KCWY News 13, P.O. Box 1540, Mills, WY 82644. Be sure to include the information listed in the form below.

Remember to include: Names and contact numbers for references who can verify or give additional information on the individual’s activities.

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*** NOTE ***
ALL FIELDS IN THIS FORM ARE REQUIRED. IF YOU DO NOT FILL OUT EVERY PORTION, YOUR INFORMATION MAY BE LOST.

Full Name of Individual Nominated:
Street Address:
City:
State:
Zip:
E-Mail Address:
Home Phone:
Work Phone:

Full Name of Individual Nominator:
Street Address:
City:
State:
Zip:
E-Mail Address: Home Phone:
Work Phone:

The following sentence needs to be completed. Please limit your essay to 300 words.

Remember to include: Names and contact numbers for references who can verify or give additional information on the individual’s activities.

This individual is nominated for the 2010 Jefferson Awards because...

IF YOU WOULD LIKE TO PRINT A COPY OF THIS FORM FOR YOUR RECORDS, YOU MUST DO SO PRIOR TO SUBMITTING YOUR NOMINATION.