Partners for Clean Air: Annual Award Nomination

State Form 55675 (R2 / 2-17)

Nomination is for actions taken during the preceding calendar year. Consideration for awards is based on voluntary actions undertaken that have a clear air quality improvement benefit.

Questions marked with a * are required.

 
Nominee Information
 
*1. Name of Nominee:
 
2. Contact Person:
 
*3. Address:
 
*4. City:
 
*5. ZIP Code:
 
*6. Telephone Number:
 
7. Cellular Number:
 
8. E-mail Address:
 
*9. Nomination Categories:
Business
Municipal
Industry
Bicycle
 
Nominee is being considered for an award because of the following voluntary air quality actions:
 
*10. Voluntary Air Quality Actions Undertaken (and completion dates):
 
Nominator Information
 
*11. Nominated by:
 
*12. Telephone Number:
 
*13. E-mail Address:
 
*14. Date (Month, Day, Year):
 
Partners for Clean Air is a coalition among businesses, industries, local government and community groups working together to improve the air quality in Northwest Indiana through voluntary actions.