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Office of Missouri Lieutenant Governor
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Senior Service Award Nominations
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Qualifications
Individuals should be at least 60 years of age and volunteer a minimum of 25 hours per year. Nominations are due March 14, 2022. If you have any issues with the form, please contact Halie Dampf: halie.dampf@ltgov.mo.gov or 573-751-1088.
NOMINEE INFORMATION
Nominee Name
*
First
Last
Nominee Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
West Virginia
Wisconsin
Wyoming
State
Zip Code
Nominee Phone
*
Nominee Email
Volunteer Organizations
*
Date of Birth
*
SPONSOR INFORMATION
Sponsor Name
*
First
Last
Sponsor Organization
*
Sponsor Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
West Virginia
Wisconsin
Wyoming
State
Zip Code
Sponsor Phone
*
Sponsor Email
*
Write-Up
Click or drag files to this area to upload.
You can upload up to 2 files.
Please upload a write-up of the nominee's volunteerism and community involvement. Be sure to include information that illustrates a difference the nominee has made and how their efforts have favorable impacted their fellow citizens, organizations and/or the community in general.
Submit