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PHILADELPHIA CHAPTER CPCU "FRANKLIN AWARD"
NOMINATION FORM
Print a copy of this page, complete the form and mail it to the
address shown at the bottom.
NB. If you would like to complete your form on-line go to the
"On-Line Version" Pageon-line.htm.
PLEASE TYPE OR PRINT ALL INFORMATION NAME OF NOMINEE: __________________________________________________ COMPANY/ORGANIZATION OF NOMINEE: _______________________________ NOMINEE'S ADDRESS: _________________________________________________ ______________________________________________________________________ TELEPHONE NUMBER IF KNOWN: ( ) - - PLEASE INDICATE THE AREA, OR AREAS, OF THE NOMINEE’S CONTRIBUTION: ( ) CONTINUING EDUCATION: Advancing the professionalism of insurance through participation and improvement of the instructional process. ( ) PROMOTING INSURANCE: Enhancement of the industry within the business community by involvement in either civic or other activities. ( ) EXTERNAL ACHIEVEMENT: Voluntary work or accomplishments in the industry outside the scope of one,s normal job responsibilities. ( ) RESEARCH EFFORTS: Activities which have led, or will lead, to major improvements in the insurance environment such as, buy not limited to, published works. ( ) INNOVATION WITHIN THE INDUSTRY: Accomplishments which have added to the overall creative excellence of the industry. ( ) SPECIFIC ACHIEVEMENTS WHICH BENEFIT THE INDUSTRY: Those milestones specifically targeted to improve the industry’s general welfare. ( ) LEGISLATIVE ACTIVITIES: Participation in government affairs leading to positive insurance legislation. ( ) LEADERSHIP: Providing guidance and direction resulting in a better insurance climate. ( ) OTHER: Please specify_____________________________________________________________ BRIEF SUMMARY OF NOMINEES ACCOMPLISHMENTS: ________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ NAME OF PERSON (NOMINATOR) COMPLETING THIS FORM: ____________________________ YOUR ADDRESS: ____________________________________________________________________ PHONE NUMBER: ( ) - - PLEASE RETURN THIS FORM TO: PHILADELPHIA CPCU CHAPTER C/O ART HANEBURY, CPCU, c/o WHARTON/DELAWARE VALLEY, 1100 ROUTE 73 North, VOORHEES, NJ 08043 |
