NCSLA Awards Nomination Form

Choose the award you wish to nominate for:	Distinguished Service Award Deadline April 16 Read award criteria before nominating!
	Herman Gatling Award for Service to Science Education Must be a member, Deadline October 20 Read award criteria before nominating!
Nominee Information
Name
Position/Title
School/Institution
Work Phone
Work Address
Home Address
Home Phone
Email
# Years Teaching Experience
# Years in Current Position
Supervisor Information (Gatling Award only)
Supervisor's Name
Supervisor's Email
Nominator Information
Name
Position/Title
Work Phone
Work Address
Email
Support Letters From: Be sure to email the following and have them complete the Support Letter Form
1. Name
Work Phone
Work Address
Email
2. Name
Work Phone
Work Address
Email
3. Name
Work Phone
Work Address
Email
4. Name
Work Phone
Work Address
Email
5. Name
Work Phone
Work Address
Email
Before you click Submit read this! When this form is submitted, you will automatically receive an email copy of the information (if you enter your email address correctly). Please forward this email to the 5 names listed above as providing support letters. Inform them that they must complete the Support Letter Form (www.ncsla.net/awards/supportletter.html) by the deadline in order for the nominee to be considered for an award. Thank you for your nomination.
Please report any problems or questions with this form to the web master.

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Updated 2/28/08