The Agency for Persons with Disabilities, Vocational Rehabilitation, Blind Services, and other disability organizations are looking
to recognize outstanding Florida employers as part of the annual Oct. celebration of Disability Employment Awareness
Month. The celebration is currently scheduled for Oct. 4 at Tallahassee City Hall.

If you are aware of an employer that has a history of hiring and supporting individuals with disabilities, then complete the following
information. Providing detailed information helps the committee in reviewing the nominations. Feel free to elaborate and use as
much space as needed.

Name of business:

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* 1. Name of business:

Address of business:

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* 2. Address of business:

Business contact person:

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* 3. Business contact person:

Email for business contact person:

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* 4. Email for business contact person:

Phone number for business contact person:

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* 5. Phone number for business contact person:

How many individuals with disabilities currently employed by company:

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* 6. How many individuals with disabilities currently employed by company:

How many people with disabilities has the company hired in the past? We need details about their longstanding commitment:

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* 7. How many people with disabilities has the company hired in the past? We need details about their longstanding commitment:

What accommodations or assistance, if any, has the business made or provided to the individual/s?

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* 8. What accommodations or assistance, if any, has the business made or provided to the individual/s?

What is the total workforce (number of people) that the business employs?

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* 9. What is the total workforce (number of people) that the business employs?

Describe why you think this business is an exceptional employer of people with disabilities:

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* 10. Describe why you think this business is an exceptional employer of people with disabilities:

Nominator name and contact information (Phone Number and email address):

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* 11. Nominator name and contact information (Phone Number and email address):

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