Jefferson  County  Growth  &  Development  Association

Jeffersonian Award Nomination Form

The Prestigious Jeffersonian Awards honor those who display civic involvement, integrity, exemplary service to the community and who make an impact on the lives of Jefferson County residents and businesses.  The Awards are given in four categories – please circle or underline which award.

Date:

Name of Nominee:

Address:

City,  State,  Zip Code:

Phone Number:

Email:

Name of person submitting application:

Phone Number:

Email:

Please Attach Additional Page(s) To Provide The Information Required Below:

1).  Please list Civic Organizations this nominee has participated in or assisted.  If nominating an

      individual, list any officer positions held in the organization.

2).  How many years has this nominee been active in assisting the community?

3).  Please describe your nominee’s civic efforts or achievements and why you believe the nominee   

       merits the Jeffersonian Award.

4).  Please list at least seven (7) people who are familiar with the nominee’s remarkable efforts and are

       willing to provide a testimonial of their achievements.

If your nominee selected, you may be asked to assist JCGDA  in the preparation of a brief video

Submit this form and letters of reference to:

Jefferson County Growth & Development Association

P.O. Box 683  ~  Herculaneum, MO  63048

Phone:  636-282-0673      Email:  executivedirector@jcgda.org