Jefferson Awards
 
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Nominate a special volunteer in your community for a 2012 Jefferson Award. Download the PDF version of the nomination form, fill out the form below, or pick one up at Nationwide Insurance agents' offices in Franklin and Delaware Counties.  All entries must be received by 5:00 p.m. or postmarked on Friday, February 10, 2012 to be considered.

Send your nomination to:
Jefferson Awards
WBNS-10TV
770 Twin Rivers Drive
Columbus, OH  43215

Rules of Eligibility:

  1. Associates of the Dispatch Media Group and associated employers are not eligible for the award but may submit nominations.
  2. Nominator information must be provided. You may not nominate yourself.
  3. An individual is not eligible if he/she has received the Jefferson Award within the last five years.
  4. A nomination form must be included when submitting nomination. Nominations must be typed or legibly printed in 300 words or less and must contain all information requested on this form.
  5. Completed nomination forms and supporting materials must be received or postmarked by midnight on February 10, 2012.
  6. Each nomination will be considered based upon: type of service and impact on the community; how much time was given to the project(s), and what was accomplished by the volunteer.
  7. Nominees may be requested to provide additional information.
  8. All decisions of the judges are final.

Download a Printable Version of the Nomination Form

Nominee’s First Name*
Nominee’s Last Name*
Nominee’s Address*
Nominee’s City*
Nominee’s State*
Nominee’s Zip*
Nominee’s Daytime Phone*
Nominee’s Evening Phone*
Nominee’s Email
Job title(s) and/or volunteer capacity or field of work for which you feel this person should be honored:
Describe in 300 words or less the nominee’s activities and contributions to society, which you feel make him/her deserving of recognition. (The decisions of the judges are based solely on the information provided on this form, so clarity and accuracy are important. Special emphasis should be put on how others have benefited from the nominee’s actions and outstanding accomplishments.)*
You have words remaining.
 
Nominator’s First Name*
Nominator’s Last Name*
Nominator’s Address*
Nominator’s City*
Nominator’s State*
Nominator’s Zip*
Nominator’s Daytime Phone*
Nominator’s Evening Phone*
Nominator’s Email*
How Did You Hear About the Jefferson Awards? Mailing Television
Newspaper Other
   
Please list at least one other person who is not related to the nominee who can verify all information.
First Person:
Name*
Email*
Daytime Phone*
Evening Phone*
Second Person:
Name*
Email*
Daytime Phone
Evening Phone
* = required field