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�'iZ,� o, f Cen�erville Nomi�catio� Fo�m <br /> City o� �'er�ervalle Ca�e�lBusus�s�e�s �'srsa� o f't�ie �'ear��eti�e Aelzieve�e� A��ard <br /> Nomination for (Please check one) ❑Citizen QBu.sin.ess ❑Lifetime Achievement <br /> Name af NomEix��e: � Phone: <br /> Address: <br /> If nominating someone for the Lifetim.e Achievement Awaxd in memory of, please list name of living spouse or <br /> relative that n�a� be contacted far fi�rther information: <br /> �ame: Phone: <br /> Addr�ss: <br /> Pleas� cheEk the organ�a�ions 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 na.me of organization in the O'THER column: I <br /> City of Centerville Coinmittee: ❑ Local Orga.nization: I <br /> ❑ LocalOrgani7.ation: ❑ School: <br /> ❑ Church: ❑ Other: <br /> ❑ Other: ❑ Other: <br /> Please ]ist below the tasks tha.t this individual has accomplished auring this past year/lifetune for Lifetime <br /> Achievement Awa�� �bat have been of benefit to o�.�r City and itTs residents: <br /> (Ifyou need additional space, please feel free to attach a separate sheet ofpaper•) <br /> Are there any other factors you feel may be important to consider regartling this nominee? <br /> Nominated by Date: <br /> Address: Phone: <br /> Nominutir�ns ar� due by �ebrraary 16, 2�O1 aaid e�n be ,placed in th� tipop boz locat�d in #he pa�' lot a# City �all. <br />