For verification purposes please place your email address in this box as well.

Please provide your/the nomination source contact information: * indicates required information.

First Name*
Last Name*
Title
Organization
Street Address*
Address (cont.)
City*
State/Province*
Zip/Postal Code*
Country*
Home Phone
FAX
E-mail*
URL http://

Please provide the following contact information for the award nominee. * indicates required information.

First Name*
Last Name*
Title
Organization
Street Address
Address (cont.)
City*
State/Province*
Zip/Postal Code*
Country*
Home Phone
FAX
E-mail*
URL http://

For which award are you nominating the candidate?

Ulrichs Community Contribution Award Eleanor Community Leadership Award Mother Courage Community Support Award

What are your reasons for nominating this candidate for the specified award? Please be specific.

Please describe in detail the actions of the nominee with regard to the specified award which in your feelings qualify the receipt of an award.

Please choose the level of the award for which you are nominating.

City/Town/Rural State Country

Please provide the names and email addresses of the appropriate second nomination sources for this nomination. City-Town-Rural-3, State-6, Country-12. Or if you are having the seconds email their nomination to us just state that in the box below. Emailed seconds must be mailed to capnom@stonewallsociety.com with the subject being: "CAP Nomination Nominee's Name"

By my electronically singing this form I am stating that the contacts listed for me are active and that the statements made by me in nomination of an award candidate are factual to the best of my knowledge.