Date: _____________
Date of receipt to committee: __________
LPTC Recognition Nomination
Name of Nominee: _____________________________________________
Nominee’s Title/Position: _______________________________________
Please select the most appropriate activity or accomplishment related to your nomination:
Customer service
Distinguished service
Personal achievement
Going the extra mile
Other (describe): _______________
Reason for Nomination:
Why are you nominating this employee?
What are some positive qualities that distinguish the nominee’s work?
Please give a specific example or examples of something this employee does/did that you
would like to recognize.
Additional Details (optional):
Relationship to the Nominee:
What is your relationship to the person you are nominating?
Other (describe): __________________
Signature of Nominator: ___________________________________________ Date: ________
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