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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