Don Davis Award Nomination Form

Please give us your contact information.

Your Name (required)
Your Phone (required)
Your Address

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Please provide the nominee's name, address, phone number and email address:

Name of Nominee:
Address of Nominee:

Telephone Number of Nominee:
Nominee's Email

Please describe the current occupation of the individual you are nominating and how this position has advanced opportunities for people with disabilities (please include specific examples of advancement and quantify the level of impact on the disability community).

Please describe past positions, work, public service, or other activities this individual has been involved in that enhance the empowerment of individuals with disabilities (please be very specific and include examples that quantify the level of impact those activities have had).

Please describe this individual’s community involvement (please include full organization names and provide specific examples of involvement and include a sufficient historical record to support awarding a lifetime achievement award).