Governor-First Lady’s Service Awards
I. Nominee Information
Nominee's Name: __________________________________________________________________________________
Mailing Address: ____________________________________________________________________________________
City: ___________________________________________ Zip Code: _________________________________________
E-mail Address: _____________________________________________________________________________________
Phone - Day: ( ) ____________________________ Evening: ( ) ________________________________
II. Nominator Information
Note: Nominators will be contacted after judging is complete.
Your Name: ______________________________________________________________________________________________
Mailing Address: _________________________________________________________________________________________
City: _______________________________________________ Zip Code: ___________________________________________
E-mail Address: ___________________________________________________________________________________________
Phone – Day: ( ) ____________________________ Evening: ( ) ___________________________________
III. Award Category
Please complete all sections. See separate sheet for General Information and Award Category Descriptions. Choose only one award category, per nomination form:
Outstanding Adult Volunteer (individual, 18 years and older)
Outstanding Youth Volunteer (individual, under age of 18)
Outstanding Corporate Volunteer Program
Honoring Ohio’s Small Business (less than 500 employees)
Honoring Ohio’s Large Business (more than 500 employees)
Outstanding National & Community Service – Participant or Program
Outstanding Volunteer Group
Outstanding National Days of Service Project (Martin Luther King Jr. Day of Service,
Global Youth Service Day, 9/11 Day of Service and Remembrance, Make A Difference Day)
IV. Required Attachments
Use no more than 4 - 8.5 x 11-inch sheets (one side). The nominee’s accomplishment must be double-spaced, with 10 point or larger type-size. Type or write legibly and provide all requested information.
Nominations will be judged on the following criteria:
A. Nominee’s Accomplishments (50 points) - In narrative form, explain why the nominee deserves
this award (include activities directly related to award category criteria). Describe
accomplishments and characteristics that may distinguish the nominee from others. B. Data (35 points) - Provide quantitative evidence within the narrative of nominee’s involvement
and impact, i.e. measurable impact on community, number of people served, length of service,
C. Supporting Documentation (15 points) – Attach supporting documents …photos, newspaper
clippings and/or letters of support (use no more than 2 of the maximum 4 pages allowed for
this section). Materials become the property of the Ohio Community Service Council and may
be used for promotional purposes. Materials will not be returned.
V. Legislator Information
Please provide the following information so that OCSC may contact an area legislator of a winning nomination:
District Number Name
U.S. Representative: ___________________ _________________________________________ State Senator: ___________________ _________________________________________ State Representative: ___________________ _______________________________________
Nominees must have at least one reference, in addition to the nominator. Relatives of nominees
may not be used as a reference. Please alert the individual they may be contacted and why.
Name: ________________________________________ Phone Number: (______) _____________________________
VII. Submission Checklist
Please initial each item before mailing your nomination!
______ I am sending 4 copies, including the original, of the completed nomination form, narrative, and supporting documentation to:
Ohio Community Service Council
ATTN: Governor-First Lady’s Service Award
51 N. High Street – Suite 800
Columbus, Ohio 43215
______ Volunteer service was completed in Ohio during the 2010 calendar year.
No exceptions will be made.
______ I understand my nomination may be disqualified if instructions are not followed. ______ No fax or hand delivered copies accepted.
______ Nomination packets must be postmarked or received by December 31, 2010