title-im-nominate-2015-pia

 

  1. Your Info

  2. First, please tell us a little bit about yourself.
  3. First Name(*)
    Please let us know your name.
  4. Last Name(*)
    Please let us know your name.
  5. City(*)
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  6. State/Province(*)
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  7. Zip/Postal Code(*)
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  8. Country(*)
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  9. ________________________________________________________________________________
  10. Your Date of Birth(*)
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  11. ________________________________________________________________________________
  12. Your Email(*)
    Please let us know your email address.
  13. OR
  14. Phone Number
    Either an e-mail address or phone number is required.
    Please note that we may contact you for more information about your nominee.
  15. Either an e-mail address or phone number is required.
    Please note that we may contact you for more information about your nominee.
  16. __________________________________________________________________________________________
  17. How long have you known the person you are nominating?(*)
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  18. What is your relationship to your nominee?(*)
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  19. Where did you first hear about The Positive Impact Awards?
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  20. __________________________________________________________________________________________
  21. Your Nominee's Information

  22. Next, please tell us about the person you are nominating for The Positive Impact Awards.
  23. First Name(*)
    Please let us know your name.
  24. Last Name(*)
    Please let us know your name.
  25. City(*)
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  26. State/Province(*)
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  27. Zip/Postal Code(*)
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  28. Country(*)
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  29. __________________________________________________________________________________________
  30. Nominee Email Address(*)
    Please let us know your email address.
  31. OR
  32. Phone Number
    Either an e-mail address or phone number is required.
  33. Either an e-mail address or phone number is required.
  34. __________________________________________________________________________________________
  35. Age:


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  36. __________________________________________________________________________________________
  37. Select a category: (*)




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  38. __________________________________________________________________________________________
  39. In your own words, why does your nominee deserve recognition for The Positive Impact Awards?
  40. Please describe in detail your nominee's specific accomplishment and what was involved in achieving it. Be sure to include the dates of the activities. (*)
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  41. __________________________________________________________________________________________
  42. How have your nominee's efforts made a difference for the better?
  43. Please describe their impact, potential impact and how they have inspired others. (*)
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  44. __________________________________________________________________________________________
  45. Is there a specific incident or turning point that motivated your nominee to take action?
  46. Please describe the moment or situation that motivated your nominee to take action. (*)
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  47. __________________________________________________________________________________________
  48. Is there anything else that makes your nominee exceptional or unique?
  49. Please describe those characteristics that set your nominee apart from others(*)
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  50. __________________________________________________________________________________________
  51. How will being recognized for The Positive Impact Awards further your nominee's cause?
  52. Please describe the impact that recognition will have on your nominee, their cause, and those they help. (*)
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  53. __________________________________________________________________________________________
  54. If you would like to share any websites or online articles about your nominee's activities, please enter up to 3 links here.
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  55. Privacy policy: For our international users, please be aware that the information you submit when registering for our services is collected in the United States of America. In addition to being subject to our privacy policy, the collection, storage, and use of your data will be subject to U.S. laws and regulations, which may be different from the laws and regulations of your home country. By registering for this service, you are consenting to this collection, storage, and use.
  56. __________________________________________________________________________________________
  57. By submitting your nomination you agree that you have read and accept our Privacy Policy
  58. Fields marked with a ( * ) are mandatory.

 

PIA2016