Name:
Working Title:
Division:
Department:
Home Address*:
Legislative District or Legislators to be notified*:
Office Address:
Please provide a few sentences about the employee’s accomplishment:
Agency Shout Out contact:
Phone Number:
* We would like to have the nominee’s home address to use on the Shout Out! so that those who receive it can write the
recipient a note if they wish to do so. Because home addresses are not public information, the agency must have a
signed statement from the Shout Out! nominee giving them permission to release their home address to OSP and others
for the purposes of Shout Out!. The agency shall retain this information. If a home address is unavailable, please
indicate the nominee’s legislative district or the names of legislators to be notified.
Information should be sent to Margaret.b.jordan@osp.nc.gov.