Community Awards Nomination Form

Community Service Awards *

Choose the appropriate award nomination from the drop down list. 

Enter required value Community Service (Individual) Community Service (Organization) A. Robert Davies MD Memorial Young Man of the Year Shirley Culp Davies Memorial Young Woman of the Year Educator of the Year Distinguished Citizen

First Name *

First name of the nominee. 

Last Name *

Last name of the nominee.

Email

Email of the nominee. 

Phone

Phone of the nominee. 

Address Line 1

Address of the nominee. 

City

Organization

Business / Organization of the nominee. 

Title

Title of the nominee (if applicable) 

Specifics (family and profession or work background) *

Please provide specific background of the nominee that you feel is appropriate to the nomination. 

How long in the Troy community? *

How long has the nominee been in the Troy community?

Contributions *

Please share contributions that the nominee has made to the Troy community. 

Additional Involvement

Additional involvement including club/organization membership, community service, offices held. 

 

Please share why you feel the nominee should receive the award selected. *

Share additional why the nominee should be selected for the award.  You may also choose to send supporting documents to Kathi Roetter at kroetter@troyohiochamber.com 

Submitted by:

Please share your name. 

Phone *

Please include your phone number. 

Email *

Please include your email. 

Date of Submission