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California School Employees Association

MEMBER OF THE YEAR AWARDS PROGRAMNomination Form

Name of Candidate _____________________________________________ Date_______________________

__________________________________________________________________________________________

Home Address City Zip Code

__________________________________________________________________________________________Work Address City Zip Code

(_____) ___________________________ (_____) _________________________________________________ Cell Phone Work Phone Email

__________________________________________________________________________________________Chapter Name Chapter Number

__________________________________________________________________________________________School District/Employer

__________________________________________________________________________________________District/Employer Address City Zip Code

__________________________________________________________________________________________Job Title of Candidate Department

____________________________________ __________________________ (_____) ___________________Name of District Superintendent/Employer Phone

_______________________________________________________________ (_____) ___________________Name of Candidate's Immediate Supervisor Title Phone

__________________________________________________________________________________________Mailing Address City Zip Code

________________________________________________________________ (_____) ___________________Chapter Officer Name Officer Title Phone

__________________________________________________________________________________________Name of Nominator Address City Zip Code

(_____) ___________________________ (_____) _________________________________________________ Cell Phone Work Phone Email

2045_1215

Area _____________

Region ___________

SUBMIT NOMINATION FORMS TO:

Fax Number:

408 432-6249

Mailing Address:

2045 Lundy AvenueSan Jose, CA 95131

Email Address:moy@csea.com

DIRECTIONS FOR NOMINATOR

Complete this form and one of the additional sections. Forward the remaining sections to the appropriate individuals.

Nomination void if completed by any CSEA staff member or if any requested information is not provided.

Forms should be filled out with Adobe Acrobat.

Call (800) 632-2128 x1234 or emailmoy@csea.comto verify receipt of nomination forms.

Nominations must be submitted or

postmarked by midnight, April 1.

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