Top 10 Under 40 Nomination Form

Nominator Information

1. Nominator Name:
2. Email:
3. Phone:

Nominee Information

4. Name of Nominee:
5. Employer:
6. Title:
7. Email:
8. Phone:
9. Address
10. City
11. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
12. Zip
13. Date of Birth Please Select Janaury February March April May June July August September October November December Please Select 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
14. How long has the nominee lived in Marion County?
15. How long has the nominee worked in Marion County?

    Nomination Questions

16. Describe the nominee’s educational background and involvement in continuing his/her education.
17. Describe how the nominee has impacted Marion County by his/her volunteer activities or special community project involvement.
18. Describe what makes the nominee an outstanding professional at their place of employment or in their occupation.
19. Describe any special leadership attributes of the nominee as an outstanding young professional.