California School Employees Association

Area _____________

MEMBER OF THE YEAR AWARDS PROGRAM

Nomination Form

Region ___________

Name of Candidate _____________________________________________ Date________________________

__________________________________________________________________________________________
Home Address

City

Zip Code

__________________________________________________________________________________________
Work Address

City

Zip Code

(_____)____________________________ (_____)__________________________________________________
Cell Phone

Work Phone

Email

__________________________________________________________________________________________
Chapter Name

Chapter Number

__________________________________________________________________________________________
School District/Employer

__________________________________________________________________________________________
District/Employer Address

City

Zip Code

__________________________________________________________________________________________
Job Title of Candidate

Department

____________________________________ __________________________ (_____) ___________________

Name of District Superintendent/Employer

Phone

_______________________________________________________________ (_____) ___________________

Name of Candidate's Immediate Supervisor

Title

Phone

__________________________________________________________________________________________
Mailing Address

City

Zip Code

________________________________________________________________ (_____) ___________________

Chapter Officer Name

Officer Title

Phone

__________________________________________________________________________________________
Name of Nominator

Address

City

Zip Code

(_____)____________________________ (_____)__________________________________________________
Cell Phone

Work Phone

Email

DIRECTIONS FOR NOMINATOR

Complete this form and one of the additional sections. Forward the remaining sections to the appropriate individuals.
Nomination void if completed by any CSEA staff member or if any requested information is not provided.
Forms should be filled out with Adobe Acrobat.
Call (800) 632-2128 x1234 or email moy@csea.com to verify receipt of nomination forms.

SUBMIT NOMINATION FORMS TO:

Email Address:
moy@csea.com

Mailing Address:
2045 Lundy Avenue
San Jose, CA 95131
Save Form

Fax Number:
408 432-6249
Email Form

Nominations must be submitted or

postmarked by midnight, April 1.
Print Form

2045_1215