Certificate of Appreciation Application/Nomination Form

Please submit nominations and suggestions by March 31, 2014 to:

Chair, SMLD Nominating Committee
c/o SMLD Office
5 Monument Square
Portland, Maine 04101

Name of Nominee (Mr/Mrs/Miss) ________________________________________

Mailing Address _____________________________________________________

City, State, Zip _____________________________________________________

Home Phone ___________________________________

Business Phone ________________________________

Title ______________________________________________________________

Organization or Firm _________________________________________________

Nominated By ______________________________________________________

Daytime Phone _________________________________

E-Mail ____________________________________________________________

Mailing Address _____________________________________________________

City, State, Zip _____________________________________________________

Nominee's Major Contributions _________________________________________

__________________________________________________________________

__________________________________________________________________

Signature _________________________________________________________

Date _________________________________________

Please attach supporting documentation and resume regarding qualifications.

Thank you!