Award:
____The Leavitt Award
____The ILCNSCA Advocate of the Year
____The Youth Leadership Award Distinguished Employer of the Year Award
____Family Support Award
Information about the nominee:
NAME:
COMPANY:
ADDRESS:
PHONE: EMAIL :
AGE:
DISABILITY:
Please describe the nominee's accomplishments and qualities which would make him/her or an employer a good candidate for the award, attach letter, if desired :
How may we contact you if more information is needed ?
YOUR NAME:
ADDRESS:
PHONE: EMAIL:
Please return to ILCNSCA by April 27, 2007.
ILCNSCA
Attn: Shawn McDuff
27 Congress St., Suite 107 Salem, MA 01970
(978) 741-0077 V, (978) 745-1735 TTY, (978) 741-1133 FAX
E-mail: Information@ilcnsca.org