Employee Nomination Form - State of Illinois

State of IllinoisIllinois Department on AgingNational Employ the Older Worker WeekSeptember 21 - 27, 2008Employee Nomination FormThis award recognizes the accomplishments of Public/Private Sector Employees and SCSEP/Title VService Enrollees. Nominees will be recognized for their dedicated efforts in acquiring knowledgeand/or skills to succeed in the workplace. All awards will be presented during the NEOWW AwardsLuncheon on Wednesday, September 17, 2008.Mail this form to NEOWW, Illinois Department on Aging, 421 East Capitol Avenue, #100,Springfield, Illinois 62701-1789; or fax it to 217-785-7744 (Attention: NEOWW).Please use one form per nomination, and make additional copies if submitting more than onenomination.Check the appropriate category per nomination: Employee SCSEP/Title V EnrolleeIndicate how your nominee exemplifies each of the following award criteria;each of the criteria is of equal weight in the selection process.Please describe the nominee’s work ethic in detail (i.e., attendance, attitude, dependability,punctuality, quantity and quality of work and adaptability).Please type or print:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Illinois Department on Aging, National Employ the Older Worker Week Nomination Form – Employee 2-----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Please describe any significant personal and/or daily obstacles the nominee has to overcomein order to participate in the workforce.Please type or print:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Please describe any special qualities exhibited which make him/her a good nominee(i.e., community involvement, volunteerism, motivation and leadership).Please type or print:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Name of Nominee: _____________________________________________ Phone: () _________________Nominee’s Home Address: _________________________________________________________________________City: _______________________________________________________________ Zip Code: ___________________Age: _____________Number of hours worked per week: _________________Name of Employer: _____________________________________________ Phone: () _________________Employer’s Home Address: ________________________________________________________________________City: _______________________________________________________________ Zip Code: ___________________Nominator: ______________________________________________________________________Nominations postmarked after June 30, 2008 will not be eligible.