Wise Award Nomination Form

The person making the nomination must provide their full name and contact information to confirm the nomination and as a way to request additional information if needed.

The Nominee's information will be used to notify them in the event they are selected as a winner.

Question Title

* 1. Contact Information for the Person Nominating

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Contact Information for the Nominee

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. How does the nominee demonstrate excellence in one or more ways that significantly empower and improve the lives of persons with disabilities?

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* 4. Give examples of how the nominee helped persons with disabilities achieve independence and dignity through meaningful employment. List the results of these activities.

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* 5. How has the nominee been involved in community activities and encouraged others to become involved in activities that support employment of individuals with disabilities?

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* 6. Provide/upload examples of merit, media documents and personal information that supports the nomination (nominations should include information how the nominee demonstrates excellence in one or more ways that significantly empower and improve the lives of persons with disabilities).