Eagle Award for Service Clubs

Nominee Name

First Name

Last Name

Nominee Phone number

Nominee Email Address

Name of Nominee Club or Organization

Club/Organization President or Representative

Club/Organization Phone Number

Club/Organization Representative's Email Address

Club/Organization Address

Address Line 1

Address Line 2

City

Zip/Postal Code

Reasons for choosing this club member are as follows

Number of years in club

Club member's service activities

Candidate background information (employment, family, community involvement, etc.)

Name of nominee's spouse and children (if applicable)