Jack B. Hefner Memorial Award Nomination Form
Directions: Print this application, fill it out and fax to NCCDD at (919) 420-7917.
DEADLINE: To be considered for the 2010 award, all nominee applications must be received in the Council offices by 5 pm, Tuesday, June 1, 2010.
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 pm on Tuesday, June 1, 2010 to:
NC Council on Developmental Disabilities
919-420-7917 (Fax); 919-420-7901 (Voice/TDD)
or mail (must be received by 6/1/10) to:
NC Council on Developmental Disabilities
3801 Lake Boone Trail, Suite 250
Raleigh, NC 27607