Partners for Clean Air: Annual Award Nomination

State Form 55675 (R3 / 1-19)

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

Industrial

Mark Siminski Bicycle Award

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.