Human and civil rights advocate nomination form NOMINEE INFORMATIONNominee Name* First Last Nominee Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Nominee Home Phone*Nominee Cell Phone*Nominee Work Phone*Nominee Personal Email* Nominee Local Association* Nominee County Association* NOMINATOR INFORMATIONNominator Name* First Last Nominator Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Nominator Home Phone*Nominator Cell Phone*Nominator Work Phone*Nominator Personal Email* Nominator Local Association* Nominator County Association* Explain how the nominee meetstwo or more of the following criteria, and respond to the following questions in narrative form:1. Initiated or engaged in human and civil rights activities which have had a community-wide impact.* 2. Contributed to the motivation of individuals or groups seeking self-determination.* 3. Has shown creativity, determination, and perseverance in achieving human and civil rights goals.* 4. Established an ongoing program or institution for the improvement of human relations and civil rights.* 5. Has taken an advocacy position at personal risk in the defense of civil rights.* Upload supporting documents Drop files here or Select files Max. file size: 195 MB.
