Carroll Awards - Application for Nomination

Application Form

I would like to nominate the following individual as a candidate for membership into the "Carroll Society", and organization for blind and vision impaired persons who demonstrate outstanding performance in their occupation or profession and serve as a positive role model.

1. Candidate's Personal Information

First Name Required Question

Last Name

Street Address

Apt/Suite/Office

City

State

Postal Code

Email Address

Phone Number

2. Candidate's Employment Information

Title

Company Name Required Question

Company Address

Apt/Suite/Office

City

State

Postal Code

Department

Phone Number Required Question

Fax Number

Email Address

Supervisor

3. Work Status and Description

Hiring Date (MM/DD/YYYY)
Note: Candidate must have been employed for one year

Full or Part Time Required Question

	Full Time
	Part Time

Number of Hours per week

Job Description Required Question

4. Nominator's Information

First Name Required Question

Last Name

Job Title

Email Address

Phone Number Required Question

Fax Number

5. Are you the nominee's supervisor? Required Question

	Yes
	No

6. Supervisor's Information

First Name

Last Name

Job Title

Email Address

Phone Number

Fax Number

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