ORGANIZATION NOMINEE INFORMATION

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

Name of the Organization

First

Mailing Address

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

Phone

Email

Website

Primary Contact Person of Organization:

First Last

Position held within the organization:

Phone

ORGANIZATION NOMINEE INFORMATION CONT'D

Please indicate the category for which the organization is being nominated:

Briefly describe five major achievements that the nominee (organization) has accomplished, in the area for which they are being nominated

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

Organizations who are being nominated by other organizations for a Shevchenko medal, will require the endorsement of two UCC member organizations, in good standing, to advance the nomination for consideration. This entails two signatories and board minutes from both organizations. Please note that individuals cannot nominate an organization for a Shevchenko Medal.

1st Nominating Organization

Address

Street Address 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.(Required)

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.(Required)

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.

2nd Nominating Organization

Address

Street Address 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.(Required)

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.(Required)

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

A letter of support may be attached

Max. file size: 256 MB.

Referee 2:

First Last

Phone

Email

A letter of support may be attached

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 this form?

YES

NO

If yes, please enter your email

Shevchenko Organization Nomination

SHEVCHENKO MEDAL ORGANIZATIONAL NOMINATION FORM

ORGANIZATION NOMINEE INFORMATION

ORGANIZATION NOMINEE INFORMATION CONT'D

Briefly describe five major achievements that the nominee (organization) has accomplished, in the area for which they are being nominated

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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