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<br />City of Centerville NomilUltion Form <br />City of~ C/8zeR/BusJness Person oldie Y"'/Li:fetJme~Awtlrd. <br /> <br />Nomination for (please check one) DCnizen <br />Name of Nominee: <br />Address: <br /> <br />DBusiness <br />Phone: <br /> <br />CJLi:f.etitne Achievement <br /> <br />Ifno~someone for the Li:retime Achievement Award in memory ot; please list name ofliving spouse or <br />relative that may be contacted for :further information: <br /> <br />Name: <br />Address; <br /> <br />Phone: <br /> <br />Please check the 0l'gJlm7.a.t1nns or groups this individual is associated with and write the name of committee that <br />this person is actively involved in. If not listed, please write the name of organi7}ltjon in the OTHER column. <br /> <br />city of CenterviIle Committee: <br /> <br />o Local Orgftni7'ation: <br /> <br />o Local OrgAni7.91ion: <br /> <br />D School: <br /> <br />- Church: <br /> <br />D Other: <br /> <br />D Other: <br /> <br />D Other: <br /> <br />Please list below the tasks that this individual has accomplished during this past year/Jifutime for Lifetime <br />Achievement Award that have been of benefit to our City and ies ~S~ <br /> <br />(If you need additional space, please feel.ftee to attach a separate sheet of paper.) <br />.Are there any other fiwtors you feel may be important to consider regarding this nominee? <br /> <br />i ' <br />,:N"otnirntted by <br />( Idress. <br />) . <br /> <br />Date: <br />Phone: <br /> <br />.1 <br /> <br />NomilllltJo1l8 tlI'tt due by FelJ1'UfDY 16, JfJ(Jl and caD be pIaeed in the drop box located In the parkiDg lot at CIty HaIL <br />