The Agency for Persons with Disabilities

							           Exceptional Employer of the Year Nomination Form
The Agency for Persons with Disabilities, Vocational Rehabilitation, Blind Services, and other
disability organizations are looking to recognize outstanding Florida employers as part of the
annual celebration of Disability Employment Awareness Month. If you are aware of an employer
that has a history of hiring and supporting individuals with disabilities, then complete the
following information. Please send your information electronically by August 24 to Melanie
Etters at APD --- melanie_etters@apd.state.fl.us.

To nominate a company, please complete the following information:
Name of business:



Address of business:



Business contact person:



Email for business contact person:



Phone number for business contact person:



How many individuals with disabilities currently employed by company:



How many people with disabilities has the company hired in the past:



What, if any, accommodations has the business made:



How many people in total does the business employ:



Describe why you think this business is an exceptional employer of people with disabilities:



Nominator name and contact information: