42nd Annual Martin Luther King Jr. Memorial Service

I Have A Dream Award Nomination Form

Please note:

Nominee must be a current or former citizen of Rock Island, IL.
Nominee must not have a current affiliation with the MLK Center as a staff member or as a member of any organization that has been created by the MLK Center.
Nominee may have a former affiliation with the King Center if the affiliation has been terminated at least one year prior to the award date.
The contribution of nominee must have benefited city of Rock Island residents.

Name of Individual or Organization Submitting Nomination

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Email

Name of Nominee

First Name

Last Name

Nominee Address

Nominee must be a current or former citizen of the City of Rock Island.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Nominee Current or Former Occupation

Please list a description of contributions (activities, community service, volunteerism) that the nominee has made to the community.

Please list nominee's organization affiliations and years of service.