Online Nomination Submission Form

New Mexico Public Service Awards Council

2009 NOMINATION FORM

ELIGIBILITY: Nominees must be residents of, or employed in, New Mexico.

CRITERIA: Either as public employees or as private citizens, nominees must have made significant contributions to the public service. Nominations must be concise and clear; if additional space is required, use no more than two additional sheets.

DEADLINE FOR FILING: MUST BE RECEIVED BY WEDNESDAY, SEPTEMBER 16, 2009
Mail or deliver to:

Dr. Dan Lopez
Office of the President
New Mexico Tech
Socorro, New Mexico 87801

1. BASIC INFORMATION ON NOMINEE (Use NA where not applicable)

Nominee's Name:

Postion:

Nominee's Phone:

Employed By:

Address of Employer:

Employer's Phone:

Supervisor's Name & Title:

Supervisor's Phone:

Nominee's Home Address:

EmailID:

Category of Award (Check One)

θ Fed or Labs

θ State or University

θ Local or indian

θ Business or Civic

2. PUBLIC EMPLOYEE JOB PERFORMANCE

For private citizens omit item 2 and provide full details in item 3.

	(A)	QUALITY OF PERFORMANCE:
		List performance awards and citie statement by employer that reflect exceptional performance. Citie specific ways in which the nominee has improved the public service , or encouraged other public employees or to pursue excellence.

	(B)	CONTRIBUTION TO JOB:
		List improvements, innovations, ideas or actions that have contributed to greater effectiveness, reduced cost, or wider acceptance of governmental operations.

3. OFF THE JOB CONTRIBUTIONS

SERVICE TO THE COMMUNITY

	For public employees, describe participation in community service, professional and service organizations.
	For private citizens, describe participation in community activities on a voluntary basis which specifically improve the public service.

4. (OPTIONAL) NO MORE THAN THREE LETTERS FROM PERSONS ATTESTING TO THE ACCURACY OF THE ACCOMPLISHMENTS OF THE NOMINEE MAY BE INCLUDED.

5. PERSON MAKING NOMINATION

Name:

Business Phone:

Home Phone:

Business Address:

Relationship to Nominee (Work Assosiate, Co-worker, ETC.)

Date: