2005 HTN Award Nomination Form
(Deadline is September 1, 2005 - Please type or print clearly)

 

General Information


Nominee ______________________________________ Email _________________________________


Organization _________________________________________________________________________

Address ___________________________________________ Phone (____) _______________________

City _________________________________________ State __________ Zip code _________________

 

 


Nomination Submitted By


Name __________________________________________ Email ________________________________

Signature _____________________________________________________________________________

Organization __________________________________________________________________________

Address ___________________________________________ Phone (____) ________________________

City __________________________________________ State ___________ Zip code ________________

 


Category for Nomination: (Select ONE Only)
 

___       Outstanding Intervention Program

___     Outstanding Prevention Program

___       Local Coalition Award

___     State Coalition Award

___       Outstanding Teen Parent

___     Outstanding Individual Professional

 

PLEASE SUBMIT FORM NO LATER THAN SEPTEMBER 1, 2005 TO:

509 Second Street, NE • Suite 200 • Washington, D.C. 20002 /  Phone: (202) 547.8814 • Fax: (202) 547.8815