Form Center

* indicates a required field

2. NOMINEE INFORMATION
4. First Name*
5. Last Name*
7. Birthdate*
8. Age*
10. House Number*
11. Street*
12. Unit
14. City*
15. State*
16. Zip Code*
18. Cell Phone*
19. Email*
21. Nominee Photo (High Resolution)*
23. Type responses for the following:*

    Describe the the services or achievements for which the candidate should be recognized. Please include the length of volunteer service, and the impact that the service had/has on the community. Describe how the candidate presents a positive image for aging. List any outstanding personality traits the candidate possesses. Include any awards or recognitions that the candidate has received.

27. Note:

    Those nominating an individual for recognition are responsible for the accuracy of the information submitted. The selection committee will not check the information or solicit additional information. The final selection will be based on the material contained on the application form and background information provided.

29. Criteria:

    The candidate is chosen for his/her service and achievement(s) after age 60; commitment to the community including the number of volunteer hours during the year; length and impact of service individual has given and other items of interest that represents a positive image of aging. The candidate must be an active volunteer during the past 10 years. Prior recipients are not eligible.  An individual or an organization may submit nominations.

Leave This Blank:


30. 1. Receive an email copy of this form.
31. Email address

    This field is not part of the form submission.

32. Submit