2007 OFFICIAL ENTRY FORM Jack B. Hefner Memorial Award Jack B. Hefner served the state of North Carolina as a member of the North Carolina Council on Developmental Disabilities (NCCDD) from 1982 until his death in 1994. As a father to a son with intellectual disabilities, "Big Jack" was willing to do whatever it takes to enhance quality of life for North Carolinians affected by disability. Jack B. Hefner's leadership inspired a generation of advocates and people with disabilities to work forcefully for full inclusion of everyone, regardless of ability. On October 27, 1994, the NCCDD established the Jack B. Hefner Award to celebrate the vision and achievement of North Carolina's families and people with developmental disabilities. The Council presents the award annually. Criteria for Nomination The NCCDD presents this award to an individual who has made significant contributions to enhancing quality of life for North Carolinians with developmental disabilities. Nominees are those individuals whose leadership, achievements, and lives advance a shared, contemporary vision of life for people with developmental disabilities. Directions: Print this application, fill it out and fax to the NC DD Council at (919) 420-7917. DEADLINE: To be considered for the 2007 award, all nominee applications must be received in the Council offices by 5:00 pm Friday, July 6, 2007. Section 1. Nomination Information Name of Nominee__________________________________________________ Name (as you wish it to appear on award)_________________________ Home Address__________________________________________________ City _________________________State _____ ZIP_______________ Phone Number: Home ( ) _______________________________ The nominee is a(n): _ Individual with a disability _ Family member of a person with a disability _ Advocate/professional Section 2. Listing of Qualifications Please attach a brief description (not to exceed 300 words) of the qualifications of the nominee for this award. Give specific information about the nominee's activities in improving the lives of people with disabilities, including examples of significant contributions and leadership. List nominee's advocacy experience _________________________________________________________ _________________________________________________________ _________________________________________________________ Areas of strength/experience/achievements in the area of developmental disabilities _________________________________________________________ _________________________________________________________ _________________________________________________________ List nominee's volunteer experience _________________________________________________________ _________________________________________________________ _________________________________________________________ Section 3. Supporting Information or References Identify three individuals who have personal knowledge of the efforts of the nominee. Name ___________________________________________________ Home Address_____________________________________________ City ___________________________State _____ ZIP _____________ Phone Number: Office ( )_________________________ Home ( )_________________________ Name ___________________________________________________ Home Address_____________________________________________ City ___________________________State _____ ZIP _____________ Phone Number: Office ( )_________________________ Home ( )_________________________ Name ___________________________________________________ Home Address_____________________________________________ City ___________________________State _____ ZIP _____________ Phone Number: Office ( )_________________________ Home ( )_________________________ Nomination Submitted by: Full Name___________________________________________________ Organization (if any)________________________________________ Title and relationship to nominee_______________________________ Home Address____________________________________________ City ______________________State__________ ZIP_____________ Phone Number: Office ( ) ____________________ Home ( )_________________________ Fax the completed form by 5:00 pm Friday, July 6, 2007 to: NC Council on Developmental Disabilities 919-420-7917 (Fax); 919-420-7901 (Voice/TDD) or mail (must be received by 7/06/07) to: NC Council on Developmental Disabilities 3801 Lake Boone Trail, Suite 250 Raleigh, NC 27607 ALL APPLICATIONS MUST BE RECEIVED IN THE COUNCIL OFFICES BY 5:00 PM, FRIDAY, July 6, 2007