AWARD CATEGORY: ALUMNI

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1 Call for Nominations The were established by Palm Beach State College to honor individuals and organizations that have made major innovative contributions toward improving the lives of others, particularly the underserved, through leadership, service and/or programs. These contributions can include the areas of education, diversity, race relations, social justice and economic empowerment. AWARD CATEGORY: ALUMNI ELIGIBILITY CRITERIA: General Instructions & Requirements New! The nominee must be a Palm Beach State College graduate who holds a degree or PSAV certificate. The nominee must be an alumnus/alumna who has performed exemplary service on behalf of others or whose accomplishments have greatly improved the quality of life for his/her community and who, by example, has served as a role model for the underserved. The packet must include ALL of the following: SUBMISSION OF NOMINATION PACKET 1. Completed Nomination Form: All pages and questions must be completed. Incomplete forms will result in nomination being ineligible for consideration. New! Please note, in additional to your signature, your application must have two additional signatures attesting to the information provided in support of the nomination and endorsing the candidate. 2. Letter of Nomination: Provide a signed letter of your nomination, summarizing why you believe the nominee should be recognized (one page only). 3. Documentation demonstrating contribution made: Example - news articles, sample of work, event flyers. (This is optional, but strongly encouraged to support your nomination) Nomination packets must be hand delivered, postmarked, or submitted electronically by 5pm on Friday, November 17, 2017 in order to be considered. Hand deliver to: Mail to: Fax to: Duncan Theatre Box Office, 4200 Congress Ave., Lake Worth Hours of operation: Monday Friday, 10am 5pm Dr. David Pena Director, Library Learning Resource Center Palm Beach State College 3160 PGA Boulevard, MS#45 Palm Beach Gardens, FL (561) MLKCelebration@palmbeachstate.edu Please note: If the nominee is selected for the award, you will be required to submit a high resolution photograph and a biography of words of the candidate by November 30, For information about the Dr. Martin Luther King Jr. Celebration, us at: MLKCelebration@palmbeachstate.edu, or call

2 Nominee Information: NOMINATION FORM Award Category: ALUMNI Name of Nominee Business Phone Home Phone Home or Business Address City State Zip Title/Position Organization Educational Background: Highest Degree of Education Name of Institution Major Field of Study (if applicable) 2

3 Nomination Information: (Provide a detailed and compelling description of related activities and/or community service, creation of initiative relevant to the eligibility criteria that the nominee has contributed to. Include nominee s personal commitment to local community and civic service.) 3

4 Description of Volunteerism: (Describe efforts and/or time and resources nomination has dedicated to service activities) 4

5 Description of Population Impact: (Describe population and reach. Include community or profile of individuals impacted by nominees work. Please quantify where applicable.) 5

6 List awards received by nominee for contributions to community life related to the eligibility criteria: (If applicable) List Articles or Acknowledgements: (If applicable) 6

7 Nominator Information: Nominated by: Mail Address: City: State: Zip: 1. Endorsed by: Name: 2. Endorsed by: Name: 3. Endorsed by: Name: 7

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