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 firstname.lastname@example.org 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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