Wig Fletcher Award Nomination

SAN DIEGO LIONS AWARD NOMINATION FORM
Please print and fill out the questionnaire and return it no later than December 31, 2003 to the:
LIONS CLUB OF SAN DIEGO
310 MARKET ST.
SAN DIEGO, CA 92101

NOMINEE:

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GROUP OR INDIVIDUAL MAKING NOMINATION:

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NOMINATOR'S PHONE NUMBER & FAX:

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NOMINATOR'S E-MAIL ADDRESS:

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ADDRESS & PHONE OF NOMINEE:

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NOMINEE'S CURRENT AND PREVIOUS PROFESSIONAL BACKGROUND:

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PLEASE NAME THE INDIVIDUALS AND GROUPS TO WHOM THIS PERSON HAS DEVOTED NON-PAID SERVICE AND INCLUDE SPECIFIC ACTIVITIES RENDERED…(.i.e., Offices held, Activities Chaired, Programs Developed, etc.)

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PLEASE MENTION ANY EXTRAORDINARY SERVICE OR ANECDOTES ABOUT THIS PERSON THAT YOU FEEL MAKE THIS PERSON DESERVE THIS AWARD.

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HAS THIS PERSON MADE A LASTING IMPACT ON SOME GROUP OR INDIVIDUAL IN SAN DIEGO? IF SO, WHAT SPECIFICALLY?

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PERSONAL INFORMATION ABOUT NOMINEE:

DATE & PLACE OF BIRTH:

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SPOUSE NAME

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CHILDREN NAMES

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Thank you for your interest!