NOMINEE INFORMATION

BEFORE YOU START, MAKE SURE YOU HAVE 1) INFORMATION ON THE NOMINEE'S ACCOMPLISHMENTS 2) NAMES AND ADDRESSES OF THE NOMINATORS AND REFERENCES FOR THE NOMINEE 3) REFERENCE LETTERS

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

NOMINEE INFORMATION CONT'D

Please indicate the category for which the individual is being nominated:(Required)

Academics

Athletics

Community Development

Culture & The Arts

Public Service

Accomplishments: Briefly describe five major achievements that the nominee has successfully attained

Accomplishment 1:(Required)

Accomplishment 2:(Required)

Accomplishment 3:(Required)

Accomplishment 4:(Required)

Accomplishment 5:(Required)

COMPOSITION(Required)

Background about the nominee, of no more than a total of 500 words, typewritten, must be included with this nomination form. It should include: - brief biographical data, - organizational memberships, - special recognition received by the nominee in the past - a description of the nominee’s accomplishments that validates their nomination for a Shevchenko Medal.

NOMINATOR INFORMATION

The application must be submitted by two nominating individuals OR one nominating organization. Names of two nominators are required to advance a nomination. Nominators must be members of a UCC member organization in good standing.

Nominator 1:

First Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

UCC Member Organization

UCC Member Organization has been notified(Required)

YES

NO

If NO, please include reasoning why:

I hereby declare the information contained in this Nomination Application to be true to the best of my knowledge.(Required)

YES

Nominator 2:

First Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

UCC Member Organization

UCC Member Organization has been notified(Required)

YES

NO

If NO, please include reasoning why:

I hereby declare the information contained in this Nomination Application to be true to the best of my knowledge.(Required)

YES

OR Nominating Organization – must be a UCC member organization in good standing.

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Name

First Last Name Position

I hereby declare the information contained in this Nomination Application to be true to the best of my knowledge.

YES

Name

First Last Name Position

I hereby declare the information contained in this Nomination Application to be true to the best of my knowledge.

YES

Attached is a copy of the excerpt from the Minutes of the meeting of the Board of Directors at which the nomination was approved.

Max. file size: 256 MB.

References: Names of two references are required by the Jury Panel. References must be able to verify the accomplishments of the nominee

Referee 1:

First Last

Phone

Email

Approval(Required)

Referee has reviewed and approved the candidacy.

Please attach a letter of support

Accepted file types: jpg, png, pdf, Max. file size: 256 MB.

Referee 2:

First Last

Phone

Email

Approval(Required)

Referee has reviewed and approved the candidacy.

A letter of support may be attached

Accepted file types: jpg, png, pdf, Max. file size: 256 MB.

Forms, which do not have this information will be considered incomplete and will not be forwarded to the Jury Panel.

Would you like a copy of the form?

YES

NO

If yes, please enter your email

form test

SHEVCHENKO MEDAL INDIVIDUAL NOMINATION FORM

NOMINEE INFORMATION

NOMINEE INFORMATION CONT'D

Accomplishments: Briefly describe five major achievements that the nominee has successfully attained

NOMINATOR INFORMATION

References: Names of two references are required by the Jury Panel. References must be able to verify the accomplishments of the nominee

Forms, which do not have this information will be considered incomplete and will not be forwarded to the Jury Panel.

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