Robert P. Shumate National Public Safety and Justice Contributor to Excellence Award Nomination Form

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* 1. Please provide the complete set of contact information for the award nominee.

Name

Company

Address

Address 2

City/Town

State/Province

Zip/Postal Code

Email Address

Phone Number

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* 2. If selected, will the nominee accept the award?

Yes

No

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* 3. Please describe the nominee's most valuable contribution(s). Provide specific examples.

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* 4. List stakeholders and beneficiaries of the nominee's contributions. Include name and email information if the stakeholder can provide a testimonial concerning this award nomination.

Stakeholder 1

Stakeholder 2

Stakeholder 3

Stakeholder 4

Stakeholder 5

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* 5. Describe the effects and/or outcomes of the nominee's contributions that were discussed earlier. Specifically, how did the nominee's contributions directly affect the improvement of information sharing in the justice, public safety, and/or homeland security domain(s).

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* 6. Briefly describe the nominator's relationship with the nominee.

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* 7. Please include your contact information as the nominator.

Name *

Company *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *