Volunteer Citizen of the Year Award - DOC by J7G2UPN

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									2012 Dayton Volunteer Citizen of the Year Award
Nomination Form
(All fields required: please print legibly)

Name of person submitting nomination:
           _____________________________________________
Address: _____________________________________________
           _____________________________________________
           _____________________________________________
Phone:     _(___)________________ _(___)________________
Fax:       _(___)________________
E-mail:    _____________________
Date of Birth: ___________________

How did you hear about the Volunteer Citizen of the Year Award?
_____________________________________________________
_____________________________________________________

What is the name of your local paper?
_____________________________________________________
_____________________________________________________

Name of Nominee(s): (if nominating someone else):
         _____________________________________________
Address: _____________________________________________
         _____________________________________________
         _____________________________________________
Phone:   _(___)________________ _(___)________________
Fax:     _(___)________________
E-mail:  _____________________


Volunteer Citizen of the Year Award Nominee profile:
(Please attach your nominee profile, in typewritten form. Nominations should be 750
words or less and should make clear the contribution made by the individual(s) to the
community)

Designated Community Group Name: _____________________________
Group Address: _______________________________________________
Group Contact Person: _________________________________________
Contact phone number: ________________________________________

Designated Community Group Profile:
(Please attach, in typewritten form, the name and a description, of the organization
selected by the nominee as the potential recipient of a $5,000 donation. Descriptions
should be 250 words or less and should clearly identify the services the organization
provides to the community. The nomination must also specify how the designated group
would make use of the $5,000 donation)

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Nominee Release

** All entries must include the signature of the nominated person or representative
of nominated group, as well as a signature from a representative of the designated
community group to be considered valid **

I/we have read the Volunteer Citizen of the Year Award Rules and know of no reason
why I/we would not be eligible to receive this award. I/we agree to follow the rules of this
competition and to abide by the decisions of the award review panel.

I/we release and discharge Direct Energy Services, LLC ("Direct Energy"), Dayton
Daily News, their respective affiliates, and all directors, officers, employees and
agents thereof (collectively, the “Released Parties”), from any and all claims or
liabilities arising from participating in, or winning, this contest.

I/we grant the Released Parties the right to photograph and/or videotape me/us and
further to use my/our name(s), face(s), likeness(es), voice(s), hometown(s), information
contained in this nomination and any other information I/we voluntarily provide, for use
by Direct Energy and/or the Dayton Daily News in connection with exhibitions, publicity,
advertising and promotional materials, without reservation, limitation or further
compensation. The Released Parties, however, are under no obligation to exercise such
rights.

I/WE HAVE READ THIS CAREFULLY AND KNOW IT CONTAINS A RELEASE OF
CLAIMS OR LIABILITIES.

Date: ___________________
Signature of Nominee
Name of Nominee (printed): _________________________________________

Date: ___________________
Signature of Designated group Representative: __________________________
Name of Representative (printed): ____________________________________

Deadline for Entries: Thursday, September 9th, 2012 at 11:59 pm. Submit online or send,
by fax, mail, or courier, your completed nomination form to:


Address:       Direct Energy                                 Fax: 412.667.6109
               Attn: Julie Hendry
               1001 Liberty Avenue, 12th Floor
               Pittsburgh, PA 15222


Nomination forms can also be filled out online at http://www2.directenergy.com/vcoy-
dayton.




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