Jr Cit Nomination Form

Name of Nominee

Date of birth (mm/dd/yyyy) (Cannot be older than 18 as of May 31, 2019)

Address (Mailing Address)

City/Town

Postal Code

Telephone Number

Nominee's Parent or Guardian

Parent or Guardian's Phone Number

Name of Nominator

Address (Mailing Address)

City/Town

Postal Code

Telephone Number

Relationship with Nominee

Name of Nominee's School

Nominator's Local Newspaper

State your reasons for nominating this person.

Please describe the extraordinary circumstances (physical, emotional or environmental) that make this nominee's accomplishments significant.

Describe how this nominee has influenced others and why the efforts succeeded.

Describe how this nominee supports and helps at home.

Describe how this nominee's attitude toward life supports the nomination.

Add further comments or additional supporting materials you feel are important.