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The David Chow Humanitarian Award Nomination Process

Please note the cut off DATE for 2011 NOMINATIONS is September 15, 2011

Directions: To complete the nomination process on-line, Three (3) Endorsement forms must be completed by three (3) separate professionals who:

  • Reside in the Nominee’s community.
  • Are NOT related to the Nominee or Nominator.
  • Either have witnessed or have direct knowledge of the Nominee's humanitarian service.
  • E-Mail forms by clicking the SUBMIT BUTTON below.
Directions: To enter this form by fax or mail, please print using the PRINT FORMS Button and follow the same instructions as above. Fax and mailing information is on the printable form.
ENDORSEMENT FORM

Nominee's Information

Nominee's Full Name:*

Endorser's Information

  

Endorser's Name:*

Endorser's Birth Date:*

(mm/dd/yyyy)

Street Address:*

City:*

State or Province:*

Zip/Postal Code:*

Country:*

Office Telephone:*

Cell Phone:

Fax Number:

E-Mail:*

1. Describe how you have witnesssed or have direct knowledge of the Nominee’s humanitarian service and how this service benefited individuals within the community.*

2. What factor/characteristics make this Nominee exceptional? *

3. The number of people helped by Nominee?:*

4. How much time does the Nominee devote to his/her humanitarian service? (Check one only)*

 
Over-time - over 40 hours per week.
Full-time - 40 hours per week. 
Part-time - up to 32 hours per week.
Monthly - up to 8 days a month.
Semi-annually - up to 12 days every six months.
Annually - up to 12 days per year.

5. How does the Nominee finance his/her humanitarian service? (Check all that apply)*

 
Receives payments
Requires no monies 
Self-funds all services
Receives outside funding
 Select all that apply and please explain:

When did Nominee begin this humanitarian service?*

 Month Year

Today's Date:

Month Day Year

E-Mail Affirmation - By checking the "I Agree" button, you hereby swear that all of the above statements are true to the best of your knowledge.*

 I Agree    I disagree
 
   
*required information  
   
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