Award Nomination Form

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Nomination Form

Nomination Instructions: Complete the nomination form and use the submit button or mail to the address noted below.

I wish to nominate this individual for the Martin Luther King Jr. "Living The Dream" Award. Each applicant also will be eligible for the Calvin C. Goode Lifetime Achievement Award.

Nominee Information
  • Name of nominee:*
  • Company/Organization:*
  • Address:*
  • City:*
  • State:*
  • Zip:*
  • Daytime phone:* (Include area code if other than 602.)
  • Other phone:
  • E-Mail Address:
  • Is nominee aware of the nomination?* Yes No (Please mark one.)
  • How has the nominee demonstrated a personal commitment to enhancing the dignity of all people beyond their regular job duties? Please include examples. (Type or copy/paste in the area below or mail in. If mailing in, please note in the text box)*

  • Dr. King taught that non-violence should be a way of life. Please describe how the nominee's efforts have addressed these core values (Type or copy/paste in the area below or mail in. If mailing in, please note in the text box)*:

    - non-violence
    - love
    - truth/honesty
    - commitment
    - respect/courtesy
    - courage
    - self-discipline
    - social justice
    - leadership
    - racial equality

  • In what way has the nominee helped to improve the quality of life for all Phoenix residents? (Type or copy/paste in the area below or mail in. If mailing in, please note in the text box)*

     

    Nominator Information

  • Name of nominator:*
  • Company/Organization (opt):
  • Address:*
  • City:*
  • State:*
  • Zip:*
  • Daytime phone:* (include area code if other than 602.)
  • E-mail:
  • How did you learn about these awards?

  • * required fields

    Please return this completed form using the submit button below. If you wish to mail or fax the nomination form to the following address, first press the submit button and print out the submission verification screen that will appear.

    Phoenix Human Relations Commission
    c/o City of Phoenix Equal Opportunity Department
    Attention: HRC Liaison
    251 W. Washington St. 7th Floor
    Phoenix, AZ 85003
    Phone: 602-495-0358

    Nominations must be received by 5 p.m. Friday, Dec. 7, 2012.

    If you have questions, call 602-495-0358/voice or 602-534-1557/TTY.

    Before you submit this e-mail form, we would like you to be aware of the city's policy on the use of its e-mail systems. The policy states that the e-mail message you are about to send: (1) is subject to public disclosure under the Public Records Law, (2) is not private or confidential and (3) is retained for one month.