Public Affairs Media Award Nomination Form

Please give us your contact information.

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

Your Email (required)

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 include a copy or link to the marketing or public affairs materials that this individual or group produced (must be produced or released within the past year).

Please describe how these marketing or public affairs materials promote persons with disabilities in an empowering and positive manner (please be specific).