Welcome To Flame Awards Nominate Form

Individual Being Nominated First Name

Individual Being Nominated Last Name

Individual Being Nominated Phone Number

Please summarize the overall contributions of this individual to the disabled community. f relevant and you have it, please provide additional background information about the person being nominated. For example: volunteer service; membership on boards; offices held; involvement in coalition or advisory groups, civic committees, task teams, etc.

What is the specific nature of the Community Service performed for which you are nominating this individual for this award?

Leadership, Social Responsibility, Mentorship, Change Agent  Please describe why you think this person should receive the Community Service Award. Please indicate how this individual exemplifies the ideal of “Service Above Self”.

Nomination Submitted By: 

First Name

Last Name