NOMINATION FORM_________________________________________
Name: ____________________________________________________
Address: ___________________________________________________
Phone: W ________________________H_________________________
E-Mail: _____________________________________________________
Years of Peace Corps Service: ___________________
RPCV Group Affiliation (If applicable): ___________________________
NOMINEE:
Name:
______________________________________________________
Address: ____________________________________________________
Phone: W ________________________H__________________________
E-Mail: _____________________________________________________
Peace Corps Years of Service: _________ Age: _____________________
Country of Service: ____________________________________________
RPCV Group Affiliation (if applicable): ___________________________
ATTACH ANSWERS TO THE FOLLOWING QUESTIONS TO THIS FORM.
1. Describe what the nominee accomplished as a PCV? (in 300 words or less)
2. Describe how the nominee has brought the spirit of volunteerism back to the United States and what has he or she accomplished through volunteering in his or her community here at home? Please provide concrete examples. (in 1,000 words or less)
3. Please attach your nominee’s resume that lists his/her volunteer experience with the organizations involved.
REMEMBER: Mail this completed form and supporting material to designated Regional Office contact by April 15, 2004.