2017 NCSEA Emerging Leadership Award Application

1. Program Description & Nominee Information

The NCSEA Emerging Leadership Award recognizes an emerging leader or manager (fewer than 3 years in a leadership position) that has improved a child support program or has enhanced the child support program in its mission in the last year, and the improvement is recognized as exemplary; that is, one to be emulated by others.

If the nominator is NOT the IV-D Director, he/she must indicate whether they have shared the recommendation with the State IV-D Director. At least one public sector individual (excluding the individual being nominated for the award) must be the nominator or an additional reference. Please be sure to complete all questions.

If you have questions about the application, please contact Cozzie King, NCSEA Professional Development, at (703-506-2880) or cozzieking@ncsea.org.

Question Title

* 1. Please provide us with the following information about the individual you are nominating:

Name:

Agency/Organization:

Address 1:

Address 2:

City/Town:

State/Province:

ZIP/Postal Code:

Job Title:

Email Address:

Phone Number:

Question Title

* 2. For what type of organization or agency does this indivual work?

State Agency

County Agency

City Agency

Private Sector Agency

Tribal IV-D Agency

International IV-D Agency

Affiliated Governmental Agency

Nonprofit Agency

Question Title

* 3. Please provide us with the following information about you.

Name:

Agency/Organization:

Address 1:

Address 2:

City/Town:

State/Province:

ZIP/Postal Code:

Job Title:

Email Address:

Phone Number:

Question Title

* 4. If the first nominator is in the private sector, please provide a nominator in the public sector.

Name:

Agency/Organization:

Address 1:

Address 2:

City/Town:

State/Province:

ZIP/Postal Code:

Job Title:

Email Address:

Phone Number: