Nomination Form for CSI National Awards

AWARD:
Please choose from the dropdown which award you are submitting for: *

NOMINEE:

(This is the person being nominated for the award.)

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Note: The Nominee may be contacted by a CSI staff member to complete a Nominee Declaration and Voluntary Background Check form and to obtain further information necessary to conduct an investigative report, if deemed necessary, such as Social Security or Passport Number.

NOMINATOR:

(This is the person primarily responsible for the preparation of the form and who can answer questions about the nomination.)

First Name *

Last Name *

Home Chapter *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

NOMINATION BY:
(Please indicate where the nomination is coming from)

	Name
Chapter	Name
Region	Name
CSI National Committee	Name
CSI National Board Officer or Director	Name

Individual Members (5 required)
If the nomination is being made by 5 CSI members, the first member is the Nominator on this form. Please add the name, home chapter, and email address of the subsequent 4 members below.

	Member Name	Home Chapter	Email
Second Member	Member Name	Home Chapter	Email
Third Member	Member Name	Home Chapter	Email
Fourth Member	Member Name	Home Chapter	Email
Fifth Member	Member Name	Home Chapter	Email

NOMINATION FOR AN INSTITUTE AWARD NARRATIVE

In a separate work document, please provide a narrative of why the nominee is deserving of this award.

Upload your narrative here. *