APPLE Award

Appalachian Leaders in Education

Community Leader, Business or Community/Civic Organization

2012 Nomination Form

Purpose: Forward in the Fifth created this award to highlight the positive impact business, civic organizations and the community can have on education and to encourage them to become involved in advancing educational progress in their community.

Eligibility: Nominee must be a business civic group of community leader in good standing within its community, be located in Forward in the Fifth’s 42-county primary service area, and desire to improve the value and outcome of educational achievement. Profit or non-profit businesses are eligible and encouraged to participate in this nomination process.

Nominee Information

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Person Submitting Nomination

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I agree that everything submitted in this application is, to the best of my knowledge, true and accurate. I acknowledge this information becomes the property of Forward in the Fifth and will be held in strict confidence.

Nominator Signature: ________________________	Date: _______________________________

Identify no more than two of the following areas in which the nominee has exhibited exceptional characteristics and accomplishment to increase educational attainment: ___ Reading/Language Arts ____ College/Career Readiness ___ Math ____ School Safety ___ Science ____ Counseling ___ Social Studies ____ Policy Development ___ Art/Humanities ____ Employment Opportunities ___ Other Academic subject: _______________ ____ Literacy ___ Attendance/Dropout Prevention ____ Assessment ___ Behavior ____ Other Areas: _______________________ ___ Health & Wellness

Please note that additional sheets of paper may be used to submit this nomination. Be sure to include the entire form to ensure eligibility.

Why is the nominee or the organization interested in improving education?

Describe how nominee has made a significant contribution in volunteer time, leadership, financial support, and/or in-kind contribution of materials or expertise to advance educational outcomes for young people. Include a description of those served, steps taken and outcomes.

How was the partnership with the school or district formed and/or developed? What contributed to the success of the partnership?

Is there anything else you would like to say about this nominee?

Applications should be submitted by March 31, 2012. Finalists will be selected and notified of their nomination. Awards will be announced in May during a special event.

All nomination information should be submitted via mail or email (no phone or fax submissions will be accepted) to:

Forward in the Fifth

2292 S. Highway 27

Somerset, KY 42501

ATTN: Rhonda Lawson

rlawson@centertech.com

(606)677-6000