Governor's Award Nomination Form

Please submit by March 25, 2009

* Award Category being entered:

* Name and/or organization of individual making the nomination:

* Nominator’s address:

* Nominator’s daytime phone number:

* Nominator’s email address:

* Name and/or organization of the nominee:

* Nominee’s address:

* Nominee’s daytime phone number:

* Summary of the program or activity being nominated:

Explanation of any limitations or special challenges faced:

* Description of the results including how the nominee’s efforts contributed to reducing impaired driving:

Please enter code: (Please click only once.)