Free 51656.pdf - Indiana

NOMINATION COVER PAGE FOR GOVERNOR'S AWARDS FOR ENVIRONMENTAL EXCELLENCE
State Form 51656 (R2 / 1-09)

Reset Form

INSTRUCTIONS:

1. Read "How to Complete and Submit a Nomination" at http://www.IN.gov/idem/5147.htm 2. Fill in the information requested below. Failure to provide all the requested information may disqualify your nomination. If you have questions about the awards program or need assistance with completing a nomination, call the Indiana Department of Environmental Management's Office of Pollution Prevention and Technical Assistance (OPPTA) at (800) 988-7901 or (317) 232-8172. All nominations must be received by IDEM by the date and time set forth in the program guidelines at the above Web address. Late nominations will not be accepted.

AWARD CATEGORY
Award Category:

CURRENT DATE
Current Date:

NOMINEE INFORMATION
Name(s) of Nominee(s) (e.g., facility, individual, organization) (List all to be recognized if awarded.): Contact person: (Check the appropriate box.) First Name: Address: City: County: E-mail Address: Type of organization being nominated: (Check the appropriate box.) Government School University Hospital Non-profit Other: Contact person: (Check the appropriate box.) First name: Organization Name (if applicable): Address: City: County: Fax Number (include area code): State: ZIP Code: Mr. Ms. Middle Initial: State: ZIP Code: Telephone Number (include area code): Fax Number (include area code): Number of Employees: Mr. Ms. Middle Initial: Mrs. Dr. Last Name: Colonel Federal Tax ID Number: Major General

Business

Industry

Individual

PERSON SUBMITTING NOMINATION (if different from contact person listed above)
Mrs. Dr. Last name: Colonel Major General

Telephone Number (include area code): E-mail Address:

If the nomination form was not submitted by the nominee, is the nominee aware they've been nominated?

Yes

No

In the box below, provide a brief summary of the project or individual being nominated. For guidance on writing the project summary, read the instructions at http://www.IN.gov/idem/5147.htm or call OPPTA at (800) 988-7901 or (317) 232-8172.

PROJECT SUMMARY