Award Nomination Form

* = Required Information

Must be received by February 19

Date Submitted *

Nominator Name /Organization *

Address *

Phone Number *

Business Name & Address *

Business Phone *

May we contact you at the above phone number?

Yes

Are you a current NJAPA member?

Yes

If you are not a current member, you must send in membership with this form or submit membership to the membership chair prior to filling out these forms.

Nominee: Volunteer, Activity Professional of the Year, Madison E. Weidner Life Achievement Award

Name of Award Category *

Name *

Home Address *

Phone *

Business Name & Address *

Business Phone *

References: Please list “TWO” references who may be contacted in reference to “nominees” outstanding service.

1. Name *

Address *

Phone *

2. Name *

Address *

Phone *

Please sign and date: *

ATTACH COMPELLED LETTER WITH THIS FORM. DEADLINE February 19.

Please note: You will not receive the nominations form back. Please make a copy for your records.

By submitting this form you agree to the terms of the Privacy Policy.