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North Carolina Leadership Achievement Award 2018 Nomination Application

The North Carolina Leadership Achievement Award is presented to an outstanding North Carolina self-advocate whose work has improved the quality of life for people with intellectual and other developmental disabilities. The award will be presented at the quarterly meeting of the NC Council on Developmental Disabilities on November 7, 2018 in Cary, NC, beginning at 5:30 p.m.

Section 1. Nomination Form

Name of Nominee
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Name(*)
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Home Address
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City
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State
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Zip Code
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Phone Number
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Section 2. Listing of Qualifications

If necessary, please attach as a separate document a brief description (not to exceed 300 words) of the qualifications of the nominee for this award. Give specific information about the nominee’s activities in improving lives of people with intellectual or other developmental disabilities, including examples of significant contributions and leadership. Please include the following:

  • List nominee’s advocacy experience
  • Areas of strength/experience/achievements in the area of intellectual or other developmental disabilities.
  • List nominee’s volunteer experience
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Section 3. Supporting Information or References

Identify three individuals who have personal knowledge of the efforts of the nominee.
NOTE: It is encouraged that references submit a short statement (maximum 300 words) in support of the nominee. Statements should include specific examples of work the nominee has done to influence positive change in the lives of people with intellectual and other developmental disabilities.
1.
Name
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Home Address
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City
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State
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Zip Code
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Phone Number
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2.
Name
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Home Address
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City
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State
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3.
Name
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Home Address
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City
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State
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Zip Code
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Phone Number
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Full name
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Organization (if applicable)
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Title/relationship to nominee
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Email(*)
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Section 4. Submission Deadlines and Requirements

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I have completed the included the following documents for consideration for the 2018 Advocacy and Leadership Awards:
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Please upload listing of qualifications
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(*)
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Submission Options: NOTE: all pages of this application must be submitted by Wednesday, August 1, 2018 in one of the three ways:
  • Email the application form to Travis Williams, Program Manager, at travis.williams@dhhs.nc.gov and info@nccdd.org
  • Fax the completed application to 919-850-2915. Please include cover sheet indicating Full Name and total number of pages.
  • Mail the application to:
    North Carolina Council on Developmental Disabilities
    ATTN: NCCDD Advocacy and Leadership Awards
    3125 Poplarwood Court, Suite 200
    Raleigh, NC 27604

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North Carolina Council on Developmental Disabilities
3125 Poplarwood Court
Suite 200
Raleigh, NC 27604
Info@nccdd.org
919-850-2901 (voice/tdd)
800-357-6916 (voice/tdd)
800-357-6916 (TTY)
919-850-2915 fax