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* 1. Please select your state:

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* 2. Date:

Date

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* 3. Nominee Name:

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* 4. Club Affiliation

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* 5. Length of Board Membership:

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* 6. Nominee Company

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* 7. Nominee Work Title:

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* 8. Nominator Name:

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* 9. Nominator Title:

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* 10. Board Participation:  Select the person's attendance percentage of regular board meetings.

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* 11. Committee Service:  The individual has served on the following committees (select all that apply)

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* 12. Leadership:  List any offices held by the nominated individual.  Include name of office and dates held.

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* 13. Resource Development:  The individual is responsible for financial contributions to their Boys & Girls Club at the following level:

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* 14. Service to Area Council:  The individual has served the Area Council in the following capacity (select all that apply)

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* 15. BGCA Education Training:  The individual participated in the following (select all that apply)

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* 16. Impact on Boys & Girls Club:  Please describe the immediate impact of this individual's involvement with your Boys & Girls Club.

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* 17. Community Relations:  Please list other service groups or agencies with which the nominee is involved.  How have these affiliations helped your Boys & Girls Club?

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* 18. Additional Information:  Please list any other pertinent information you would like to share concerning the nominee's Club service, awards received, personal or family information, college attended, etc.

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* 19. Supporting Documentation:  Please upload any supporting documents here:

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