Nominee's Name:           

Month of Nomination:    January February March April May June July August September October November December

(Note:  Chapter president's may nominate only one (1) officer and one (1) member for each month.)

Award Category:     Member Officer   (If officer, indicate office held: )

Number of Jaycees recruited by the nominee during this month? 

Chapter's net membership growth (+/-) this month? 

Has the nominee previously received this award  this year?  Yes No

Will nominee be in attendance at the next state meeting?     Yes No

Summarize the nominee's specific activities this month that were outstanding and worthy of special statewide recognition:

Nominating Chapter:    

Nominated By:              

Nomination Deadline is the 5th day of each month.