Nomination Form for
William Dodd Founder's Award and James Pattee Education Award

To nominate an individual for either the 2012 William Dodd Founder's Award or the 2012 James Pattee Education Award, please complete the information requested below. Nominations will be accepted until January 30, 2012.

* = REQUIRED FIELDS
Award	*	Select One William Dodd Founder's Award for Distinguished Service James Pattee Award for Excellence in Education Consider Applicant for Both Awards
Nominee's Name	*
Title
Organization
Address
City
State		Select One Non-US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
ZIP
Country (if outside U.S.)
Phone
Fax
Email	*
Bio   *
Please upload supporting documentation to let us know why you believe this individual deserves consideration. Please be specific. The acceptable file types for uploading are (.doc .docx, .pdf, .txt)
AMDA State and National positions held and specific contributions.
Submitter's Information
Your Name	*
Title	*
Organization	*
Address	*
City	*
State	*	Select One Non-US Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming
ZIP
Country (if outside U.S.)
Phone	*
Fax
Your E-mail	*
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