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:
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.