NOMINATION FOR

THE DEAN SPINDLER STATE RECLAMATIONIST OF THE YEAR AWARD

NATIONAL ASSOCIATION OF

STATE LAND RECLAMATIONISTS

INSTRUCTIONS:

When completing this form, you may use additional pages as needed to explain any part. If additional pages are used please cross reference your answer/response to the corresponding question. All answers/responses should be concise and brief. PLEASE FEEL FREE TO PHOTOCOPY THIS FORM!

Accompanying this form you may wish to attach any supportive documents, newspaper articles, letters of commendation, etc. to support your nomination. Nominees are limited to employees of State governments employed or active in the field of land reclamation.

Submit this completed form along with any attachments, so that it is received no later than April 15, to:

NASLR
c/o Anna Harrington
SIU Coal Research Center
Mail Code 4623
Carbondale, IL 62901-4623

PART I

A. General Information - Nominee

Full Name:

Business Address:

Business Phone Number:

Employed or Formerly Employed by the State of:

Immediate Supervisor:

Business Address:

Business Phone Number:

Is Nominee a:

full-time, current

full-time retired

part-time only

full-time retired, now working part-time

past-full time, not retired, now working part-time

other (please specify)

Number of years nominee has worked in reclamation:

Present (or last if retired) job title and brief description of job responsibilities:

General Information - Nominator

Name:

Business Address:

Business Phone Number:

Do you wish your name to be kept confidential?

How long have you known the nominee? .

In what relationship have you worked?

Are you a full-time or part-time retired employee who is working or has worked in reclamation? .

PART II

Nominee's Performance

Provide a general discussion of the nominee's performance, dedication, attitude, and commitment to timely and quality reclamation.

How has the nominee demonstrated effectiveness in implementing your state's program?

Has the nominee performed activities that exceed the responsibilities of his/her job requirements? If so, discuss.

Do you believe the nominee has performed his/her/ job responsibilities morally, ethically, and legally?

Additional Performance Information

Provide any other information you may feel important in the evaluation of your nominee - anything you feel makes him/her worthy of outstanding recognition.

Identify any attachments you have included in this application.

To the best of my knowledge and available resources, the information contained in this application reflects an accurate description of the nominee's performance and abilities.

Signed:

(Nominator)