Connecticut Hall of Fame  

Connecticut Hall of Fame

NOMINATION FORM

  
 

The following nomination is submitted to the Connecticut Hall of Fame for the Year: 2013

Nominee’s background information should be as complete as possible.
 

ELIGIBILITY

Nominees eligible for election to the Connecticut Hall of Fame must be current or former residents of Connecticut, shall have performed outstanding service to humanity, to the State of Connecticut or to the United States, and/or be known for their public service throughout the State; or, if nonresidents, shall be eminently distinguished in their profession or in literature, science, arts, humanities, industry, statesmanship or military affairs, which work shall have brought honor or distinction to Connecticut or have contributed to the State's heritage.

PERSONAL INFORMATION

Nominee Name 
Place of birth     
Date of birth      
CT Residence (City/Town)    
Approximate dates of residence          
Other Address (if not a CT resident)  

CONNECTION TO CONNECTICUT

Identify the nominee's connection to Connecticut (examples: born and raised in the state, educated here, most notable achievements here, etc.)



MAJOR FIELD OF ENDEAVOR / NOMINEE'S TITLE(S)
(Example: Author, Educator, Humanitarian, Political Activist, Scientist, Social Activist, etc.)

OUTSTANDING ACCOMPLISHMENTS AND/OR CONTRIBUTIONS FOR WHICH NOMINEE SHOULD BE CONSIDERED (Describe in what ways the nominee's achievements or contributions have been of enduring value)

PERSON SUBMITTING NOMINATION

Name:
Address:
City:
State:
Zip:
Work Phone:
FAX:
Email:
Relationship to Nominee:
Agency or Organization Affiliation: