Employee Nomination Form - State of Illinois

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.