Please print this, complete it,

and return to your region rep

or

Copy it and email it to your region rep

MFBSA

Nomination Form

For

Region Individual Family-Based

Worker of the Year Award

Name of Nominee: Agency:

Program:

Address:

Phone/Fax: Email:

Agency Position and Duties

Reason for Nomination: (Goal Reached, Special Skill, Notoriety in agency, Successes, Specialty, etc.

MFBSA Member since (if known):

MFBSA Involvement (if known:

Your Name: Agency:

Phone: Email: