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The John W. Coombs Award: and 201 6 Nomination Form

This document contains nomination forms for the John W. Coombs Award and the Agency of Distinction award given out by United Way of Eastern Maine. The forms request information about the nominee/nominating agency such as their contact details, service history, impact statement, and letters of reference. Nominations must be received by July 8, 2016 and should be mailed to the United Way of Eastern Maine office in Bangor.

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NEWS CENTER Maine
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87 views2 pages

The John W. Coombs Award: and 201 6 Nomination Form

This document contains nomination forms for the John W. Coombs Award and the Agency of Distinction award given out by United Way of Eastern Maine. The forms request information about the nominee/nominating agency such as their contact details, service history, impact statement, and letters of reference. Nominations must be received by July 8, 2016 and should be mailed to the United Way of Eastern Maine office in Bangor.

Uploaded by

NEWS CENTER Maine
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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and

The John W. Coombs Award


2016 Nomination Form

(Nominees will be considered for both)


Nominee name
Mailing address
Telephone

City

State Zip

City

State Zip

City

State

Zip

e-mail

Business
Business address
Business telephone

e-mail

Nominator name
Agency or Organization
Mailing address
Telephone

e-mail

Please provide the following information separately. Complete nomination packets must include all of the following information:
Nominee service history:

Primary beneficiary of nominees service


All organization(s) for which the nominee volunteers
Duration of service
Time commitment: weekly/monthly/yearly
The nominees greatest contribution
Type of service provided
Awards, recognition, and honors the nominee has received

Impact statement of 350-500 words which states the following:


The nominees community service contributions
Specific examples of the nominees work and its impact
Amount and duration of service
Letter of reference:
[At least] one from someone who knows the nominee through his/her volunteer activity
[At least] one from someone who knows the nominee on a personal basis
Nomination forms must be received by 5:00 p.m. on Friday, July 8, 2016.
Send or deliver to :

United Way of Eastern Maine


700 Main Street, #1
Bangor, ME 04401

Agency Of Distinction
2016 Nomination Form

Name of Agency:
Director/President of Agency:
Board Chair Person/President:
Mailing address:

City

Business telephone:

Fax:

Person completing nomination form:

State

Zip

e-mail
Telephone :

Mailing address:

City

Business telephone:

Fax:

State

Zip

e-mail

Connection of this person to the nominating agency:


Please provide the following information separately:
County(ies) served
Number of clients served
Services received by clients/community
Client satisfaction with services; how this is measured
Volunteer satisfaction; how this is measured
Needs that this agency meets which have been identified by the community
New or emerging needs for which this agency has developed unique or effective solutions in the last year
What makes this agency an Agency of Distinction? Attach a statement of 350-500 words which describes the work of the agency,
what community needs it meets, how it demonstrates that it is a good steward of human and financial resources, how it shows
respect and recognition for the work of its volunteers, and how its clients or the community have benefited from agency services.
Please include up to three letters from volunteers and/or clients in support of this nomination.

Nomination forms must be received by 5:00 p.m. on Friday, July 8, 2016.


Send or deliver to :

United Way of Eastern Maine


700 Main Street, #1
Bangor, ME 04401

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