Alabama Senior Citizens Hal of Fame Nomination Form

2015 ALABAMA SENIOR CITIZENS HALL OF FAMENOMINATION FORM

This form allows you to nominate a person to be inducted into the Alabama Senior Citizens Hall ofFame or receive a Special or Honorary Award based on the nominees' contributions to the welfare of, and service to, senior adults in Alabama.

(Please print or type)

Name of Nominee ______

Address______

______Phone ______

E-Mail Address ______

Date of Birth ______Check if nominee is 60 years or older as of August 1, 2015 □

Birth Place ______Name of Spouse ______

School Attended ______Highest Level Completed ______

Honors and Awards______

______

Employment before retirement of the nominated senior: (Check all that apply)

_____ Business (including retail, power, communications)_____ Self-Employed

_____ Industry-Manufacturing-Agricultural and Energy_____ Federal

_____ Commerce-Banking-Savings-Investment-Insurance_____ Military

_____ Professional-Legal-Accounting_____ Medical-Doctor-Health Professional

_____ State_____ City-County-Local Public Agency

_____ Education-Public_____ Education-Private

_____ Other (including non-profit)

NOMINATED BY: (Please print or type)

Your Name ______

Address ______Phone number______

E-Mail address ______Signature: ______

Please return this Nomination Form no later than June 15, 2015 to
Hall of Fame Selections Committee, Alabama Department of Senior Services,
ATTN: Robyn James, P. O. Box 301851, Montgomery, AL 36130-1851

or Email: .

Supplemental Questions

Emphasize uncompensated and exceptional services to older citizens

(Attach additional paper to compete this section)

Summarize the nominee’s contributed services to seniors in their employment years prior to first retirement.

Summarize the nominee’s contributed services to seniors during second career work activities.

Summarize the nominee’s achievements and contributed services to seniors since most recent retirement.

Please list all nominee’s activities. Cite the type of service, program, along with the frequency and duration of the contribution of the active participant, offices held and committee appointments when applicable.

Department of Senior Services/Area Agency on Aging:
Church/place of worship disaster relief (i.e. sustenance/comfort/inspiration):
AARP/RSVP/Meals on Wheels (e.g. tax preparation assistance, senior driver education):
Other retirement organizations (e.g. leadership, state, officer and board positions held in NARFE, Retired Officers/Enlisted, ARSEA, AEA, AERA):
Senior center (development, operation, maintenance, culinary, grounds):
Community (e.g. furnish transportation to seniors, assist with household or outdoor tasks, transport and delivery ofgroceries to needy seniors, volunteer at rescue missions, contribute to and participate in fund raising for seniors):
Tutoring/teaching/mentoring and expertise sharing (e.g. Master Gardener):
Volunteer at health, assisted living, nursing home or hospice facilities (e.g. home health caregiver):
Red Cross volunteer, organ or systematic blood donor:
Member of task force (e.g. the Elder Justice Alliance):
Member of retirement or senior health coverage board:
Board member of county DHR,mental health board or governing advisors of an Area Agency on Aging:
Other (e.g. special event volunteers):

Attach sheets to this form showing an explanation of all outstanding contributions your nominee has made for the benefit of, and service to, senior citizens. GIVE AS MANY DETAILS AS POSSIBLE.

RECOGNITION OF CENTENARIANS AND THOSE MARRIED 65 YEARS OR MORE

The Senior Citizens’ Hall of Fame will also recognize Alabama seniors aged 100 years or older and couples married 65 years or more at the ceremony. If you would like to nominate someone you know in this category please provide the following information:

Name of person or couple to be recognized______

Address______

City ______Zip ______Date of birth or marriage ______

Your name ______Telephone ______

Address ______

City ______Zip ______E-mail ______

Or Email .