Annual Rev. Dr. Martin Luther King, Jr.
Awards Program Nomination

Adult Human Relations Award
Youth “I Have A Dream” Award

I. Nominee Information

Nominee Name:*
Street Address: *
City/Zip code: *
Phone: Home: Work:
Email address: *
Occupation: *
Community Service Hours/Week: *

II. Nominator Information

Nominator:*
Street Address: *
City/Zip code: *
Phone: Home: Work:
Email address: *
I have I have not notified the nominee of this nomination.

Anyone interested in nominating an individual should complete this form and return with a legible text narrative (1,000 words or less) by mail or fax. Relevant supporting documents may be attached:*