Illinois Veterans Patriotic Volunteer and Appreciation Award

ILLINOIS VETERANS’ PATRIOTIC VOLUNTEER AND APPRECIATION AWARD Nomination Form

Please read the Nomination Guidelines prior to completing this form. Please attach the veteran’s up-to- date DD214 as well as a written summary of the nominee’s achievements following the guidelines.

______Nominee’s Name Date & Place of Birth

______Home Address, City & State, Zip Code

______Telephone (work & Cell) Email

______Location of Illinois Residency

______Nominator’s Name Relationship to Nominee (Comrade, relative, etc.)

______Home Address, City & State, Zip Code

______Telephone (Work & Cell) Email

I have read the nomination guidelines and attest that the above information is accurate and true. I also affirm, to the best of my knowledge that the nominee stated above is in good legal standing.

Signature of Nominator ______Date: ______(Required)

I have read the nomination guidelines and attest that the above information is accurate and true. If selected as a recipient of the Illinois Veterans’ Patriotic Volunteer and Appreciation Award, I agree to attend a public appearance with the Illinois Department of Veterans’ Affairs; and, I agree to participate in all media and outreach efforts and activities.

Signature of Nominee ______Date: ______(Required)

SEND COMPLETED FORM TO: [email protected] (email) or to mailing address below: Illinois Department of Veterans’ Affairs Attn: Illinois Veterans’ Patriotic Volunteer Appreciation Award 100 West Randolph St., Suite 5-570 Chicago, IL 60601-3219 ILLINOIS VETERANS’ PATRIOTIC VOLUNTEER AND APPRECIATION AWARD Nominating Service and Achievements (Be sure you have read the Nomination Guidelines prior to completing this form.)

Date Summary of Achievements/Accomplishments/Awards

______

Use the section below to describe and provide more details: Summary of Achievements/Accomplishments/Awards Details Continued……..

Please attach documentation(s) that will substantiate the nominee’s service and accomplishments described above (i.e., news articles, relevant online biographies and/or copies of commendations, etc.).