IMPACT AWARD NOMINATION

Nominee:

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* 1. Nominator's Name

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* 2. Your Relationship to the Nominee

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* 3. Nominee's Information

Organization name:

Address: (street, city, state, zip)

Phone:

Email:

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* 4. Name of CEO/Executive Director of the nominee organization

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* 5. Tax Designation ( 501(c)3)

Yes

No

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* 6. Annual Budget

Under $1 million

Over $1 million

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* 7. Board Chair of Nominee Organization

Name

Organization

Email

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* 8. Mission Statement (50 words)

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* 9. Brief History of the Organization. (250 words)

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* 10. Describe the community need addressed by this organization. (250 words)

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* 11. Why are you nominating this organization? (100 words)

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* 12. What has changed in the community because of the work of this nominee? (250 words)

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* 13. The Award recognizes nonprofits that exemplify our values: Community, Collaboration, Sustainability, Integrity, Impact. Provide a specific example of how the nominee demonstrates these values. (250 words)

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* 14. Describe how the nominee collaborates with other nonprofit organizations to enhance services or increase the effectiveness of nonprofits. Identify at least two key partner organizations and the benefit of the collaboration. (500 words)

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* 15. Describe the nominee's efforts to leverage in-kind resources from community members and stakeholder organizations. (150 words)

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* 16. Why is the work of this nominee different, unique or a best practice model for other nonprofits? Specify what other nonprofits can learn from this organization. (500 words)

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* 17. Share a brief story or anecdote about the nominee that illustrates its impact within the community. (250 words)

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* 18. Has the nominee's work been publicly recognized in the past two years? If yes, by which entity?