NCCDD - Leadership Award Nomination Application

North Carolina Leadership Achievement Award Nomination Application

The North Carolina Leadership Achievement Award is presented to an outstanding North Carolina self-advocate whose work has improved the quality of life for people with intellectual and other developmental disabilities. The award will be presented at the quarterly meeting of the NC Council on Developmental Disabilities in November in Cary, NC.

Section 1. Nomination Form

Name of Nominee

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Name(*)

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Home Address

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City

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State

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Zip Code

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Phone Number(*)

Please use this number format XXX-XXX-XXXX

Email

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Section 2. Listing of Qualifications

If necessary, please attach as a separate document a brief description (not to exceed 300 words) of the qualifications of the nominee for this award. Give specific information about the nominee’s activities in improving lives of people with intellectual or other developmental disabilities, including examples of significant contributions and leadership. Please include the following:

List nominee’s advocacy experience
Areas of strength/experience/achievements in the area of intellectual or other developmental disabilities.
List nominee’s volunteer experience

‘Listing of Qualifications’ is attached. Invalid Input

Section 3. Supporting Information

Identify three individuals who have knowledge of the efforts of the nominee.

NOTE: It is encouraged that individuals submit a short statement (maximum 300 words) in support of the nominee. Statements should include specific examples of work the nominee has done to influence positive change in the lives of people with intellectual and other developmental disabilities.

1.

Name

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Home Address

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City

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State

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Zip Code

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Phone Number(*)

Please use this number format XXX-XXX-XXXX

Email

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2.

Name

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Home Address

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City

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State

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Zip Code

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Phone Number(*)

Please use this number format XXX-XXX-XXXX

Email

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3.

Name

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Home Address

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City

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State

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Zip Code

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Phone Number(*)

Please use this number format XXX-XXX-XXXX

Email

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Section 4. Personal References (Required)

Identify three (3) individuals as personal references who may be contacted to help evaluate the qualifications of the nominee.

Reference 1

Name(*)

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Phone Number(*)

Please use this number format XXX-XXX-XXXX

Email(*)

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Reference 2

Name(*)

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Phone Number(*)

Please use this number format XXX-XXX-XXXX

Email(*)

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Reference 3

Name(*)

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Phone Number(*)

Please use this number format XXX-XXX-XXXX

Email(*)

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Nomination submitted by:

Full name

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Organization (if applicable)

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Title/relationship to nominee

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Home Address

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City

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State

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Zip

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Phone Number(*)

Please use this number format XXX-XXX-XXXX

Email(*)

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Section 5. Submission Deadlines and Requirements

I have completed and included the following documents for consideration for the Advocacy and Leadership Awards:

Section 1: CompletedSection 2: Completed with ‘Listing of Qualifications’ (required) attached.Section 3: Completed with ‘Short Statements of Support’ (optional) attached.Section 4: Completed (required)Section 5: Submitted ON OR PRIOR TO, July 14, 2023. Invalid Input

I have read and followed the submission guidelines for my application to be considered for the Advocacy and Leadership Awards. I understand my application will not be considered if the following documents are not completed. Invalid Input

Please upload listing of qualifications

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(*)

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Submission Options: NOTE: all pages of this application must be submitted by July 14, 2023 in one of the three ways:

Email the application form to Pam Hunter Dempsey, Systems Change Manager at [email protected] and [email protected]
Fax the completed application to 984-920-8201. Please include cover sheet indicating Full Name and total number of pages.
Mail the application to:
North Carolina Council on Developmental Disabilities
ATTN: NCCDD Advocacy and Leadership Awards, 2010 Mail Service Center, Raleigh, NC 27699-2010

North Carolina Council on Developmental Disabilities - NCCDD

North Carolina Leadership Achievement Award Nomination Application

Section 1. Nomination Form

Section 2. Listing of Qualifications

Section 3. Supporting Information

Section 4. Personal References (Required)

Nomination submitted by:

Section 5. Submission Deadlines and Requirements

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