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Nominee Information *

Address *

City *

ZIP *

Phone *

Email Address * ERR

Type of Nominee:     Business      Individual      Organization

Nominator's Name *

Address *

City *

ZIP *

Phone *

Email Address (*copy of nomination forwarded) * ERR

The nominee is being submitted for the following reason(s) and/or action(s). Check all that apply:

For his/her advocacy on behalf of, or other exemplary support of Somerset County citizens with disabilities.

For making a commitment to promote positive awareness of the needs of Somerset County citizens with disabilities.

For outstanding service demonstrating significant impact in meeting the needs of Somerset County citizens with disabilities.

Please use the space below to describe how the nominee has met the cirteria as specified above; give any additional information that should be considered. If possible or applicable, please attach copies of any supporting documentation. *

Optional: Supporting Nominee Documentation (5 file limit). Allowed types: .doc(x), .pdf, .rtf, .jpg, .png)

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Previous winners and County employees are not eligible to be nominated. Word and PDF applications are available upon request. Please contact Sandra Avellan at 908-704-6334 or e-mail: DisabilityServices@co.somerset.nj.us if you have questions.

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