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KHA17nomPacket

KHA17nomPacket

NOMINATION CHECKLIST (A

NOMINATION CHECKLIST (A separate checklist is required for each award nomination you make.) I am nominating ________________________ for this award: ______________________. To support that nomination, I have enclosed: Three sets of these documents: _____ Checklist, Nomination Form and Narrative (does not exceed two pages) One copy _____ Supporting Materials Appropriate to Award Category (these will not be returned to me or to the nominee) One _____ Digital photograph of the nominee to be used at the awards ceremony should the nominee receive an award One to three _____ Digital photographs of the nominated project, program or publication that demonstrate the contributions of the group or individual 2017 Kentucky History Awards 5

NOMINATION FORM (three pages) (A separate nomination form is required for each award nomination you make.) NOMINEE INFORMATION Nominee (organization, group or individual)________________________________________ ____________________________________________________________________________ Project title (if applicable)_______________________________________________________ Address______________________________________________________________________ City__________________________ State/Zip___________ Phone_______________________ Nominee’s E-mail address __________________________________ Fax__________________ AWARD CATEGORY If your nomination is for a service or special award, select only ONE award category for which you nominating this person, group, project or organization. Service Awards _____ Thomas D. Clark Award of Excellence _____ Award of Distinction _____ Frank R. Levstik Award for Professional Service _____ Lifetime Dedication to Kentucky History Award Special Awards _____ Brig. Gen. William R. Buster Award _____ Volunteer Organization or Group (Award categories continued on next page) 2017 Kentucky History Awards 6

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