NOMINATION FOR EMPLOYEE OF THE YEAR

An employee who has overcome handicaps to achieve success in the workplace.

Deadline: Wednesday, Oct. 1, by 5:00 p.m.

1. Nominee's Name:
2. Home Address
Street Address Address Line 2 City State ZIP Code
3. Business Address
Street Address Address Line 2 City State ZIP Code
4. Home Phone:
5. Business Phone:
6. Name of Employer:
7. Nominee's Job Title:
8. Describe nominee's disability and rehabilitation:
9. Describe any difficulties the nominee encountered in adapting to his or her work or living environment. (Address nominees initiative, resourcefulness, and perseverance in overcoming the barriers.)
10. How has the committee increased public awareness and facilitated employment of other disabled persons?
Submitted by:
Date:
MM slash DD slash YYYY