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Please read the rules and regulations at pages.solution-tree.com/2012awards before submitting your nomination.

The nomination deadline is December 31, 2012. Award winners will be announced January 14, 2013. Winners will be recognized during the PLC at Work™ Summit awards ceremony, 10:00–10:30 a.m. on Friday, February 22, 2013.

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* 1. Nominee Information

School/District:

Address:

City:

State:

ZIP:

Country:

Email Address:

Phone Number:

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* 2. If nominating a team, please list all team members' names and titles here.

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* 3. Nominator Information (you)

Name/Title: *

Occupation: *

City:

State: *

Email Address: *

Phone Number: *

Video and written essays are required. Video submissions must not exceed three minutes. Written essays must be less than 500 words. Essays must be original. No copyrighted writings, music, video, or images may be used in the essay.

Be sure to tell us where you are on your school improvement journey, what progress you have made, and how $10,000 could make a difference in your school or district.

*See YouTube Help (PDF) at pages.solution-tree.com/2012awards for help with posting video to YouTube.

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* 4. Please enter a link to your video submission (of less than 3 minutes in length):

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* 5. Please enter your written essay (of less than 500 words) in the box below. It should answer the question, "How is the nominee redefining excellence in his/her school, district, or classroom?"

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* 6. I hereby give permission for any or all of the information from this form and submitted entry materials (video, audio, or written) to be shared with persons interested in promoting the Solution Tree (re)defining Excellence Awards. I understand that this information could be used in press releases, publicity in all media, and printed materials. By submitting this nomination, I represent that the nominee has consented, consistent with all federal, state, and local laws, regulations, and other requirements, to the disclosure of this information to Solution Tree and its affiliates and representatives for use in connection with the 2013 PLC at Work™ Summit. I understand I must verify the accuracy of all information contained in this nomination form to the satisfaction of Solution Tree. I further represent that the nominee has consented to the use of all information stated in the nomination form, in all media and formats throughout the world, without compensation, in connection with this award and the promotion of the 2013 PLC at Work™ Summit.

I have read the Solution Tree (re)defining Excellence Awards Rules and Regulations and agree to be bound by their terms.

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* 7. Please sign and date electronically, then submit your nomination.

Signature:

Date:

Note: Be sure to print your completed nomination form for your records before submitting it. If you have trouble submitting via email, you can scan and attach a copy of the printed form to an email. The email address is nomination@solution-tree.com. You can also fax your completed form to 812.336.7790, to the attention of Kim Ennis.