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Eli Segal Nomination Form
All fields must be completed in order to evaluate your nomination. Please fill in the nomination form below. All nominations are due no later than May 22, 2009. Awards will be presented June 22-24, 2009 as part of the National Conference on Volunteering and Service in San Francisco.
Name of Nominee 
Name of AmeriCorps Program
Dates of Service (dd/mm/yy - dd/mm/yy)
Name of Program Supervisor
Contact Info. of Program Supervisor
(Phone # and e-mail address)
Nominee's Current Organization
Nominee’s Address
Nominee’s City, State, Zip
Nominee’s Email
Nominee's Work Phone (
Nominee’s HomePhone (
Nominee’s Fax # (
Nominator’s Name
Nominator’s Phone
Nominator’s Email
Relationship to Nominee

Entrepreneurial Spirit

How has the nominee demonstrated outstanding vision with regard to innovative approaches to building community through service?

How did the nominee find creative ways to solve a problem or address an issue?

How might the innovation developed by the nominee help advance the field of national service? Specifically, how has it contributed to the growth and advancement of the AmeriCorps Alums movement?

Convener & Connector
How does the nominee bring people together to reach a common goal?

How does the nominee utilize the power of community, bringing resources and ideas together to solve a problem?

How has the nominee shown that his/her efforts are focused on benefiting the greater good and not serving individual interest?
Service and Civic Engagement
How does the nominee engage in service and civic engagement in his/her community whether local or national?
How does the nominee mobilize others to participate in service and civic engagement in their community?
How is the nominee active in government and policy as an advocate for national service as well as issues important to his/her community?

Impact & Sustainability

What results have been achieved thanks to the work of this nominee?

How has the nominee impacted change beyond his/her immediate community of influence?

Explain how the initiative will/would sustain itself in the absence of the nominee.

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