Nonprofit
Organization and/or Program:
Nonprofit
Organization and/or Program Director:
Contact
Person:
Phone:
Address:
Nonprofit
Status:
501(c)3
501(c)6
Other __________________
Is
the organization a current member of the PWC-GM Chamber?
___________
(You
may wish to contact the Chamber to check the current status,
703-368-6600).
Nomination
submitted by:
Company:
Phone:
Nominations
must be received by 12:00 Noon on or before Friday, January 24,
2003 at the Chamber office, 8963 Center Street, Manassas, VA
20110. All
information must be typed and appear on this form.
If you do not have a typewriter, you may retype this form
on a computer. The
type must be 10 point or larger.
No attachments will be accepted. Originals are preferred,
but faxed nomination forms will be accepted at 703-368-4733.
You may request a copy of the application form from Kris
Welsh at the Chamber, 703-368-6600 ext 15, or request one by
e-mail at [email protected]
or you may fill this application out on line at www.pwcgmcc.org.
Mission
Statement of organization:
Who
does the organization/program serve?
What
are the accomplishments of the organization/program in the last
year?
Describe
the organization�s/program�s impact on the community and on
the quality of life of those served.
Please
write, in 25 words or less, how you would like your
organization described to the general public if you were the
recipient of the Shelley Krasnow Service Award.
(This piece will be
used to describe your organization at the event and may be used in
Chamber publications.)
Any
Additional Information.
