Nomination Form

You may submit up to two additional pages of supporting documents (ex:  newspaper clippings).  

The Awards Committee will choose a final recipient based solely on the information you provide, so please note all the contributions and achievements, relevant to the award.  If you have questions or need clarification, please contact Tricia Gorden at 574-284-7108 or e-mail us at tgorden@realservices.org

You may print the following form and mail it to the address below (please use this method if you wish to include additional pages of supporting documents) or you may submit the form on-line.

Deadline for nominations:  4:00 p.m., April 2, 2010

You must use the TAB key on your keyboard to go from field to field in the form below.
Pressing the Enter key will submit the form.

Nominee Information
Award Category:
Phone Number:
Street Address:
Describe specific activity(ies) this person has performed which benefited an older adult or a group of older adults or a disabled individual. Explain the impact these activities have had on you, other individuals or the community.
Please include any additional information which you feel is relevant to the award. (Examples include: recognitions/awards, attitude or life philosophy, commitment, how long they have been volunteering, the number of people who they have served, number of hours a month they give, etc.)
Your Information (Optional)
Name:
Phone Number:
Street Address:

Or Mail Nominations to:

REAL Services, Inc.
Attn: Tricia Gorden
P.O. Box 1835
South Bend, IN 46634