OMB CONTROL # 1093-0004
EXPIRES 03/31/2010

NATIONAL AWARD NOMINATION APPLICATION

PART I: NOMINATION INFORMATION

A. Name of Nominated Individual or Organization/ Group as to be inscribed on award:
Please select the category that most closely
identifies your organization.(Select only one - required) 		Individual
School Program
  Is the school a Take Pride School? Yes No
Youth/ Youth Group
Corporation or Business
Non-Profit Organization
Faith Based Group
Federal Event/ Program
State Event/ Program
Local Government Event/ Program
Public/ Private Partnership
B. Nominee: Contact information for individual or organization being nominated
Name of individual or the contact person for organization/ group:
Title:
Street Address:
City, State, Zip:
Phone:
FAX:
E-mail:
For organizations or groups, in 100 words or less, please describe the organization or group and their mission.
Is the nominee aware of this nomination? yesno  Note: Nominee must be aware of and consent to nomination.
C. Nomination Submitted by: (If you are nominating yourself, skip C and go to Part II)
Name:
Title (if applicable):
Organization (if applicable):
Street Adress:
City, State, Zip:
Phone:
FAX (optional):
E-mail:
Relationship to Nominee:
PART II: PROJECT AND ACTIVITY INFORMATION
A. Site location and Ownership
Site Name:
Address:
City, State, Zip:
Phone Number:
Land Owner/ Manager (Check all that apply) Federal
State
County
City
Tribal
Other; Please Specify:
B. Is the project ongoing? YesNo
If no, how long did event/ project last? Days Months
Did the activity occur between May 1, 2007 and April 30, 2008? YesNo
*If not, project or activity does not qualify for an award this year.
C. Type of Activity
Please select primary purpose of event/ project. Select no more than three options.
Habitat Restoration
     Example: Riparian/ Streamside; Plants (weeds, native plants); Wildlife; Range; Fish; Prairie; Forest; Wetland
Soil/ Water Conservation
Education/ Interpretation Outreach
Research/ Monitoring/ Studies
     Example: Plants; Wildlife; Archaeological; Historic/ Cultural Fossils; Watershed; Soil; Minerals; Mapping; Toxins
Construction
     Example: Trails/ Pathways; Fences; Signs
Species Management
     Example: Fish; Wildlife; Horses and Burros
Historic/ Cultural Restoration or Improvement
     Example: Site; Structure
Clean-Up/ Maintenance
     Example: "Adopt-a" effort; Grounds or Gardens; Trails
Host/ Site Steward/ Interpretaion
     Example: Campground Host; Park Guide; Visitor Information
Administration
     Example: Data Entry; Office; Public Relations
Other; Please specify
D. Volunteer Information
Total number of event/ project volunteers:

Total event/ project hours for award year:

E. Community or Partner References
Please list three contacts, with phone numbers, who are familiar with the history and success of the project/activity.
Name: Phone:
Organization:
Name: Phone:
Organization:
Name: Phone:
Organization:
PART III : PROJECT SUMMARY

A. Project Summary.
Summarize the scope of the project/ activity. Please list no more than five major goals and resulting accomplishments. Quantify whenever possible (i.e. number of miles groomed, bags/lbs. of trash collected, etc.). Please limit your response to 5,000 characters (approximately two single-spaced pages).

B. Project Impact.
Summarize the impact and benefits of this project/ activity on the event site, natural resources and community. Please list no more than five major benefits/ impacts for the resulting beneficiaries. Quantify the impact whenever possible. Please limit your response to 2,500 characters (approximately one single-spaced page).

C. Project Partnerships.
Briefly describe the collaborative or partnership efforts associated with this project/ activity. Please indicate any funding sources and/ or in-kind donations received for this project/ activity. Please limit your response to 2,500 characters (approximately one single-spaced page).
By submitting this application, the nominator attests that the application has been filled out to the best of their knowledge and that the individual or organization nominated has been informed and has agreed to the nomination.
I Accept I Decline
Please insert your initials
Privacy Act Statement

This information is being collected to further the purposes of the Take Pride in America Act (16 U.S.C. 4601 et seq.). Furnishing this information is voluntary. It will be used to select finalists and winners of Take Pride in America Awards, using an outside panel of judges, and for the public awareness campaign authorized by the Act. Information collected via this application is covered by the Privacy Act of 1974 (5 U.S.C. 552a) and Privacy Act System of Records Notice Interior OS-14: Take Pride in America System. Access to this information is limited to only those officers and employees of the Department of the Interior who have a need for the information in the performance of their duties. Disclosure without the consent of the subject of this information is restricted unless required by the Freedom of Information Act to those listed in the Notice under its "Routine Uses" section and to those identified in 43 CFR 2.56.


Paperwork Reduction Act Statement

The Paperwork Reduction Act of 1995 (44 U.S.C. 3501 et seq.) requires us to inform you that this information is being used to select finalists and winners of Take Pride in America Awards. Response to this request is voluntary. The public reporting burden for this collection of information is estimated to average one hour per response, including the time required for gathering the data needed and completing and reviewing the collection of information form. Send comments on the burden estimate or on any other aspect of this collection of information, including suggestions for reducing this burden, to Department of the Interior, Executive Director, Take Pride in America, Room 3559, 1849 C Street N.W., Washington, D.C., 20240. Under the Paperwork Reduction Act, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.