Question #2: How long has the nominee been providing the needed service?
Briefly describe the amount of time given.

Question #3: How active and involved has the volunteer nominee been in providing
the needed service? Briefly describe what the nominee did.

Question #4: How did the nominee’s service contribute to people with blindness or
partial sight and the community? Briefly describe the change and
impact made by the nominee.

Question #5: Briefly describe other related activities the nominee initiated or
participated in.

Question #6: Please make any additional comments you wish to provide about
the nominee.

Nomination Submitted By:

Nominator’s Name: ____________________________________________________
First Middle Last

Nominator’s Address: ____________________________________________________
Street, PO Box, Rt No City State Zip

Nominator’s Phone: ( )_________________ E-mail: ______________________

Nominator’s Signature: ________________________ Date Signed: _____________

Send to:
Lilac Services For The Blind • Nancy Domanico Award For Distinguished Service To The Blind
Nomination Selection Committee • N. 1212 Howard St., Spokane, WA 99201
(509) 328-9116 • Nomination Deadline: October 1, 2004, at 4:30 p.m.