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Lonnie D. Burton Achievement Award Nomination Form

ELIGIBLE RECIPIENT


The Lonnie D. Burton Achievement Award is presented annually to an individual who, through the assistance of a Community Action Program, has achieved a significant level of self-sufficiency and independence, while recognition is given to the local Community Action Agency’s role in helping the nominee(s) to help themselves. This award focuses on the personal progress and achievements of the individual(s) nominated. CAA employees are not eligible for this award unless they are former recipients of CCCAA services.


Nominating Agency Information

* Agency Name:
0/50
* Agency Address: (Street address, City, State, Zip code)
0/250
* Agency Phone Number:
0/50
* Agency Contact Person: (This is the individual we will reach out to should we need additional information regarding the nominee.)
0/50

Nominee Information

* Nominee's Name:
0/50
* Nominee's Family Size: (Please list the number of individuals in the nominee's household.)
0/50
* Nominee's Education Level:
0/250

Please use the spaces provided below to describe the (1) circumstances that caused the nominee to seek your agency's help. Please include the dates assistance was provided to the nominee. Also, describe (2) what the CAA did for the nominee (i.e., services, case management, etc.), as well as (3) the nominee’s commitment to achieving their personal goals. Please also discuss any (4) contributions the nominee has made to their community and (5) any additional responsibilities that the nominee committed to while working towards their goals.

* Circumstances that caused the nominee to seek your agency's help:
0/500
* What your agency did for the nominee: (i.e., services provided, case management, etc.)
0/500
* Describe the nominee's commitment to achieving their goals:
0/500
* Describe any contributions the nominee has made to the local community:
0/500
* Describe any additional responsibilities the nominee committed to as they worked towards their goals:
0/500