Chapter IV - Eastern Region Nomination - North Carolina Rehabilitation Association

Chapter IV (East Region) Award Nomination Form

* Indicates required field

Nominating Category *

Nominee Information

Name *

First

Last

Employer Name/Company (If employer nomination) *

Email (if known) *

Phone Number (if known) *

1. If applicable, list NRA/NCRA positions currently or recently held, including length of terms. Highlight any which have special bearing on the appropriateness of the award. *

2. If applicable, list honors, citations or other forms of recognition that bear on the nominee’s contributions to persons with disabilities and their rehabilitation. *

3. If applicable, list other affiliations and/or community activities of the nominee that may be helpful in the evaluation process. *

4. In narrative form, state why you believe this individual or organization should receive an NCRA award. Your statement may be as long as you wish, and you may add explanatory or corroborating statements from other individuals or organizations. Statements should be specific as to the nature, scope, and importance of the contribution made by the nominee to the rehabilitation of persons with disabilities or to their well-being. *

Nominator Information
*Must be a current NCRA member

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Position Held (if applicable) *

Phone Number *

Email *

Acknowledgement

By typing your name in full below you are acknowledging that you are a current NCRA member. You also knowledge that your type name is representative of your signature, which signifies that the information provided above is true and accurate to the best of your knowledge.

Full Name *

Today's Date *

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Chapter IV (East Region) Award Nomination Form

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