2017 NCSEA Outstanding Leadership Award Application

1. Program Overview & Nominee Information

The NCSEA Outstanding Leadership Award recognizes an individual who has demonstrated outstanding management and leadership of an organization, team, project or initiative that has demonstrably impacted the child support program and has inspired others over the course of several years to improve the child support program and serve the best interest of children.

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 (703-506-3271) 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: