Nominee's Name

Nominee's School

School Address

City

State

Zip Code

Nominee's Grade (Must be Grade 7-12)

Year Nominee Will Graduate High School

Nominee's Grade Point Average

Nominee's Phone (include area code)

Awards (if applicable)

Community Activities (if applicable)

School Activities (if applicable)

Your Name

Relationship to Nominee

Home Phone (include area code)

Work Phone (include area code)

E-mail address