2016 NOMINATION FORM
Return form to P.O. Box 274, Blanchester, OH 45107

(Select One.)

_____Businesswoman of the Year
_____Businessman of the Year
_____Citizen of the Year

Your Name: _______________________________ Phone Number: _______________

Name of Nominee: _______________________________________________________
Address: _______________________________________________________________
Phone Number: ____________Place of Employment: ___________________________
Position: _____________________________Duration of Employment: _____________

Use additional pages as needed

Contributions related to his/her Company’s Success:



Service Activity Related to Community Improvement Projects:



Service Contributions to Local Institutions, or Humanitarian efforts:



Membership in Organizations and Offices Held:



Past Awards and/or recognition:



Why should nominee be selected?:
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