Louis E. Yavner Award Application

Question Title

* 1. Type of Nomination

Teaching Award

Community Award

Question Title

* 2. Name of Candidate

Question Title

* 3. Title or Position

Question Title

* 4. For Teaching Award, please complete the following:

Name of School

School District

School Address (Street)

City/Town

Zip

Question Title

* 5. Home Address

Street

City/Town

State

Zip

Question Title

* 6. Phone number

Question Title

* 7. Email address:

Question Title

* 8. Name of Nominator

Question Title

* 9. Title or Position

Question Title

* 10. Address

Organization (if applicable)

Street

City/Town

State

Zip

Question Title

* 11. Phone number

Question Title

* 12. Email address

Question Title

* 13. Reference or Supporter Name

Question Title

* 14. Telephone number

Question Title

* 15. Email Address

Question Title

* 16. Reference or Supporter Name

Question Title

* 17. Telephone number

Question Title

* 18. Email Address

Question Title

* 19. By submitting this questionnaire, you acknowledge that you personally know the candidate and will submit letter of nomination electronically to EMSCURRIC@MAIL.NYSED.GOV by December 15.

Yes, I acknowledge

Comment(s) if any