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									               National Crime Victims’ Rights Week 2013
                         Victim Service Awards Nomination Form

Nominee Information

Name:                                  Address:                                       Phone:


Email:                                 Organization:



Nominator Information

Name:                                  Address:                                       Phone:


Email:                                 Relationship to Nominee:




Please select award(s):

 Victim to Victorious Award
         Awarded to victim or other individual personally impacted by crime that has raised the profile of
         victims’ issues in the district

 Exceptional Service Provider Award
         Awarded to service provider who delivers exceptional services to victims of crime

 Innovative Service Award
         Awarded to field practitioner who has developed and implemented innovative victim service
         programs and/or projects

 Outstanding Volunteer Award
         Awarded to volunteer(s) who offer their time and personal resources to help victims

 Youth Service Award
         Awarded to youth who dedicate time and effort to support victims in their communities
Summary of Accomplishments:

Please summarize the nominee’s accomplishments and your reason for nominating this individual,
program, or organization. If more space is required, please attach additional pages.




To the best of my knowledge, all of the information contained in this application is true and correct:

Signature:____________________________________

Date:_________________
Notice of Collection of Personal Information and Consent to be Nominated

       To the Nominee:

       Personal information contained in or required by this form will be collected and used by the
       District Attorney and the selection committee to administer the Victim Services Awards of
       Distinction, including processing and assessing the information provided. Except as required by
       law, personal information will be disclosed only for administering the Program as described
       above. Personal information contained in or required by this form will also be used in the
       development of public communication materials regarding your selection as a nominee or a
       recipient of a District Attorney Victim Services Award of Distinction.

       I have read the nomination form, including any additional information provided and the Notice of
       Collection of Personal Information, and I consent to its use and/or disclosure for the purpose of
       being nominated for a District Attorney Victim Service Award. I agree that any relevant
       information may be released publicly for the purposes of acknowledging my nomination and/or
       receipt of award.

       Signature of Nominee:__________________________


       Date:__________________




Please send completed nomination forms and nominee consent by

                              FRIDAY, MARCH 22, 2013
to:

       Victim Service Awards of Distinction
       Amanda Griffin
       District Attorney Victim Witness Division
       201 LaPorte Ave., Suite 200
       Fort Collins, CO 80521-2763
       griffiaa@co.larimer.co.us
       Fax: 970-498-7250



       All applications will be reviewed by an awards panel composed of representatives from the
       community and staff of the District Attorney’s Office. Nomination forms must be received by
       March 22nd, 2013 to be eligible for consideration. Only completed and signed nomination forms
       and supporting documents will be accepted.
 will be accepted.

								
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