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Exemplary Employee and Frank J. Lucchino Distinguished Service Awards
Nomination Form - PAPER Version


GENERAL INSTRUCTIONS:
  1. Type all information. Please complete all sections.
  2. Provide a written explanation of why the nomination is being made. Nominations may be enhanced by testimonials, letters of appreciation or commendation from associates and/or citizens with first-hand knowledge of the employee’s actions, or proof of enhanced productivity as reflected in cost savings, revenue generated or increased efficiency.
  3. The person submitting the nomination must sign the last page of the form and any attached documentation. Unsigned nominations will not be accepted.
  4. To nominate, fill out the form below, print, sign and mail.  Any applicable documentation must be attached.
    Mail To:
    Terry Conroy
    County Manager's Office
    436 Grant Street, Suite 119
    Pittsburgh PA  15219
  5. Nominations may be submitted at any time and will be accepted on an ongoing basis.
INDIVIDUAL NOMINEE:
NAME/TITLE:  DEPARTMENT/DIVISION: 
       
GROUP NOMINEE:
NAME/TITLE:  DEPARTMENT/DIVISION: 
NAME/TITLE:  DEPARTMENT/DIVISION: 
NAME/TITLE:  DEPARTMENT/DIVISION: 
NAME/TITLE:  DEPARTMENT/DIVISION: 
NAME/TITLE:  DEPARTMENT/DIVISION: 
       
NOMINATED BY:
NAME:   PHONE:  
ADDRESS: CITY/STATE/ZIP: 
EMAIL ADDR:
DATE:   NOMINATOR:  
 
AWARD CATEGORY – Check the appropriate category. Select one category only:
 
REASON FOR SUBMISSION: (Required)
Briefly describe the reason for nominating the employee or employee group.     
Attach supporting documentation. This form may be duplicated if additional space is required.     
 
 

Signature:  ______________________________________

Date:

 ______________________________

This form and any supporting documentation will not be returned to you.  Any false statement, lobbying effort and/or violation of the above instructions will disqualify the nomination.  The award panel reserves the right to interpret this process as it deems appropriate.  Your signature on this form releases the County and any/all of its employees and representatives from any liability in all aspects of this process; furthermore, your signature authorizes the award committee to investigate and verify any information contained in this nomination.  All information will be kept confidential.

  
Office Use Only (Reference Number):
Manager's Office Use Only:
Received By: