Community Quarterback Nomination Form * Required before final submission

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1 Community Quarterback Nomination Form * Required before final submission Assessment of Organization and Nominee Eligibility Is the organization a non-profit organization? Yes/No Does the nominee volunteer for an organization located in Wisconsin? Yes/No Is the nominee currently volunteering on a regular basis; weekly or monthly? Yes/No Does the organization compensate the nominee for his/her time? Yes/No Community Quarterback Nomination Overview This nomination form consists of four pages. To complete this form, you will be asked to provide specific information as outlined below. You can save and return to this form at any time by clicking Save & Finish later at the bottom of each page. Page 1: Volunteer nominee information. Page 2: Nominator contact information. Page 3: General information about the non-profit organization the nominee volunteers for. Page 4: Attachments to support the nomination. Nomination forms must be completed and submitted online no later than the end of the day Friday, December 3, You will receive confirmation via when the nomination form is submitted successfully. All nomination forms will be reviewed by Friday, December 24, We will send an to the nominator after all reviews are completed. When typing information in this form, use upper and lower case letters. Do not use all CAPS unless necessary for the information being provided. Volunteer Nominee Information Tell us about the nominee and their volunteer history. * Today s Date: * First and Last Name: Approximate Age: * Street Address: * City, State and Zip Code: CQB November, 2010 Page 1

2 * In addition to volunteering, is the nominee: Employed Full-time Employed Part-Time Retired Student Not Sure * Provide two (2) words that best describe the nominee: How long have you known the nominee? * Number of Months or Years: * Specify Months or Years * Are you the nominee s: Manager/Supervisor Friend Co-worker Other If other, please explain: * How many years has the nominee volunteered for this organization? How much time does the nominee volunteer each week or year? Hours per Week OR Hours per Year * What is the nominee s primary responsibility? * What program area does the nominee primarily serve? Animal Welfare Arts & Culture Athletics & Fitness Civic & Community Drug/Alcohol Abuse & Violence Services Education Education/Religious Elderly Environmental Health & Wellness Homeless Human Services Hunger Military Religious * What sets the nominee apart from other volunteers? CQB November, 2010 Page 2

3 Nominator Information Tell us about the person nominating the volunteer. The information provided in this section will be utilized for future correspondence regarding this nomination. * Prefix: * First Name: * Middle Initial: * Last Name: * Address: Are you employed by the non-profit organization? If yes, what is your title? * Provide the preferred mailing address and phone number, including the area code, we can use to contact you. CQB November, 2010 Page 3

4 Non-Profit Organization Information * Name: Other name or abbreviation the organization is known as: * Organization s mission: * Select the description that best describes the organization s purpose: Animal/Wildlife/Waterfowl Welfare Arts & Culture Athletic Benefit Civic & Community Education/Other Education/Private Education/Private/K-12 Education/Private/Post High School Education/Private/Preschool Education/Public Education/Public/K-12 Education/Public/Post High School Education/Public/Preschool Environmental/Agriculture Government/Military Health & Human Services/Disabilities Health & Human Services/Disaster or Crisis Health & Human Services/Domestic Violence Health & Human Services/Drug or Alcohol Abuse Health & Human Services/Medical Health & Human Services/Other Health & Human Services/United Way Homeless Hunger Non-profit/Other Religious * Geographical area supported by this organization: WI North (534) WI North (715) WI Northeast (920) WI Southeast (262, 414) WI Southwest (608) * Street Address: * City: * State: CQB November, 2010 Page 4

5 * Zip Code: * County in which the organization is located: * General phone number, including the area code (i.e. (920) ): * General fax number, including the area code (i.e. (920) ): Website address, starting with www (i.e. Federal Employer Identification Number (EIN): Tax Status: 501c(3) Tax Exempt Non-profit organization Other Private Operating Foundation Private Nonoperating Foundation Suspense 509(a)(1) 509(a)(2) under 170(b)(1)(A)(vii) 509(a)(3) under 170(b)(1)(A)(viii) 509(a)(4) Tax Exempt Provide CES Number. If other, provide explanation. CQB November, 2010 Page 5

6 Attachments If you have additional information you feel would further support the nomination of this volunteer, follow steps 1. to 4. to upload one document at a time. The additional information can also be mailed to: Community Quarterback Nomination, Green Bay Packers, 1265 Lombardi Ave., Green Bay, WI OR sent via to: Follow these steps to upload each document: 1. Click the Browse button to browse the location of that document on your computer; 2. After locating the document on your computer, click on it to highlight it; 3. Click on Open or OK. The document location and name will appear as the File Name; 4. Click Upload. Repeat steps 1. to 4. to attach another document. If you have completed the form and uploaded additional documentation, go to the end of this section and click on Review & Submit. You will have an opportunity to review the contents of the form and complete any required fields that may be missing information. You must go to the end of the Attachments section one more time and click on Submit. We cannot review or consider your nomination form unless the Submit button is clicked and you receive confirmation the form was successfully submitted. Upload The maximum size for all attachments combined is 25 MB. Please note that files with certain extensions (such as exe, com, vbs, or bat ) cannot be uploaded. CQB November, 2010 Page 6