Forms • Merced County, CA • CivicEngage

2023 Volunteer Recognition Program Nomination Form

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Please note that all nomination forms must be received by Monday, April 3rd, 2023 at 5:00 p.m. in order to be considered for public recognition at the meeting of the Merced County Board of Supervisors. Should you have any questions regarding the nomination process, contact Mike North at (209) 726-2744.
Note: Complete only one of the sections below. Complete either "Individual Nominee/Volunteer Information" or "Organization Nominee Information", but not both.
Individual Nominee/Volunteer Information
Name of Individual
Street Address
City
State
Postal Code
Phone/Daytime Contact Number
Email Address
Supervisorial District individual resides or performs volunteer work
Name of Organization individual performs volunteer work
Type/scope of Volunteer Work
Average number of hours volunteered by the individual during the past twelve (12) months
(Or) Organization Nominee Information
Name of Volunteer Organization
Street Address
City
State
Postal Code
Agency Director/Contact Person
Phone/Daytime Contact Number
Email Address
District(s) organization conducts volunteer work
Brief purpose of organization

Please Complete all sections below
Why does the individual or organization you are nominating deserve this recognition? Briefly describe below in 250 words or less, your reasons for recommending this individual or organization for the Volunteer Recognition Program, including the type of volunteer work carried out, as well as any interesting or unusual information about the nominee or group.
Verification
In order to qualify for consideration, a nominee must have one referee that may be contacted to verify the scope/extent of the nominee’s volunteer activities. The Referee should be familiar with the accomplishment(s) for which the volunteer or organization is being nominated. The Referee may not include the nominator, the nominee or any person related to the nominee.
Name of Referee
Street Address
City
State
Postal Code
Phone/Daytime Contact Number
E-mail
Nominator (name of person nominating individual or group for recognition)
Name*
Street Address*
City*
State*
Postal Code*
Phone/Daytime Contact Number*
E-Mail
Position/Firm or Agency*
Attachment
Attachment 1
DEADLINE TO RECEIVE NOMINATIONS IS 5:00 P.M. MONDAY, APRIL 3RD, 2023.

* indicates required fields.

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