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Entry Form Materials
Awards Program
You may download the form as an
HTML (File - Print), portable document format (PDF), or Microsoft
Word file. Please
use a separate form for each entry. Please type or print.
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Reader from the Adobe web site. 
- The application reply deadline is Friday, September 25, 2009
- The 10th Annual Award Ceremony will be held in Washington, DC in the spring of 2010
- HTML (printable - use your browser's print function to print this page)
- PDF (8pp, 62k)
- Word (8pp, 126k)
Clean Air Excellence Awards Program
ATTN: Pat Childers
U.S. Environmental Protection Agency
Office of Air and Radiation
Mail Code 6102A, Room 6510A
1200 Pennsylvania Ave., N.W.
Washington, D.C. 20460
Clean Air Excellence Awards Program
ENTRY FORM
Please use a separate form for each entry (you may photocopy this form as necessary). Please type or print.
| Project Name: |
________________________________________________________ |
| Project Location: (if applicable) |
________________________________________________________ |
| Organization Responsible for Project: |
________________________________________________________ |
(If your entry is selected for an award, information from the preceding three lines will appear on the award certificate. If your project involves multiple partners, please attach a separate sheet listing all organizations.)
Entry Form Contact Information
| Submitted by: |
___________________________________________________________________ |
| Title: |
___________________________________________________________________ |
| Organization: |
___________________________________________________________________ |
| Address: |
___________________________________________________________________ |
| Telephone #: |
___________________________________________________________________ |
| Fax #: |
___________________________________________________________________ |
| E-mail: |
___________________________________________________________________ |
| Would you like to receive future awards program
announcements?
Yes____
No____ |
|
*NOTE: If you are nominating an individual for the Thomas W. Zosel Outstanding Individual Achievement Award, please enter his or her name on the "Project Name" line above, and enter your name on the "Submitted by" line above.
Check one: Which award category applies to your entry? (You may select only one category.)
Clean Air Technology
Community Action
Education/Outreach
Regulatory/Policy Innovations
Transportation Efficiency Innovations
Thomas W. Zosel Outstanding Individual
Achievement Award
Would you like to be considered for the Gregg Cooke Visionary Program Award?
Yes
No
On an attached sheet(s), please provide a narrative description of your entry and explain why it should receive a Clean Air Excellence Award. Please limit your description to 500 words or less. Be sure to address the evaluation criteria for the category applicable to your entry. To the extent possible, please specify your project's contribution to air pollution emissions reductions.
Please provide three independent references for your entry. Be sure to include a name, address, telephone number, fax number, and e-mail address for each reference. To the extent possible, your references should represent the stakeholders that are affected by your entry. Award reviewers may contact these references for additional information or clarification.
Reference #1
| Name: |
___________________________________________________________________ |
| Title: |
___________________________________________________________________ |
| Organization: |
___________________________________________________________________ |
| Address: |
___________________________________________________________________ |
| Telephone #: |
___________________________________________________________________ |
| Fax #: |
___________________________________________________________________ |
| E-mail: |
___________________________________________________________________ |
Reference #2
| Name: |
___________________________________________________________________ |
| Title: |
___________________________________________________________________ |
| Organization: |
___________________________________________________________________ |
| Address: |
___________________________________________________________________ |
| Telephone #: |
___________________________________________________________________ |
| Fax #: |
___________________________________________________________________ |
| E-mail: |
___________________________________________________________________ |
Reference #3
| Name: |
___________________________________________________________________ |
|
| Title: |
___________________________________________________________________ |
|
| Organization: |
___________________________________________________________________ |
|
| Address: |
___________________________________________________________________ |
|
| Telephone #: |
___________________________________________________________________ |
|
| Fax #: |
___________________________________________________________________ |
|
| E-mail: |
___________________________________________________________________ |
|
| How did you hear about the Clean Air Excellence Awards Program? | ||
| __ Website search engine | ||
__ E-mail distribution |
||
| __ Journal/publication | ||
| __ Website article/link to awards website | ||
| __ Co-worker/business associate | ||
| __ Mailing | ||
| __ EPA press release | ||
| __ Other: _______________________________ | ||
| Mail entry form to: | The Clean Air Excellence Awards Program |
|
ATTN: Pat Childers |
||
| U.S. EPA, Office of Air and Radiation | ||
| Mail Code 6102A, Room 6510A | ||
| 1200 Pennsylvania Ave., NW | ||
| Washington, D.C. 20460 | ||