LRWA Annual Awards Nomination Form

INDIVIDUAL AWARD CATEGORIES

SYSTEM AWARD CATEGORIES

System/Facility Name *

Address (provide mailing and physical) *

Address Line 1

Address Line 2

City

State

Zip Code

Parish System in which System is Located *

Office Phone (copy) *

Cell Phone

Email *

Name of person submitting nomination *

First

Last

Title of person submitting nomination *

Legal operating name of system being nominated: *

How long has system been in operation? *

How many employees does the system have? *

How many customers does the system serve? *

Has system ever been out of compliance? If yes, when and for what reason? *

What do you believe entitles this system to receive this award *

Provide a brief background on the system being nominated *

Legal operating name of system individual is employed with: *

Name of individual being nominated: *

First

Last

Title/Position with system: *

How long has nominee worked in water/wastewater industry? *

What level and type of Operator Certification does nominee hold? *

What do you believe entitles this individual to receive this award? *

Provide a brief background on the individual being nominated *