NOMINATION FORM Legal Aid of Western Missouri Honorable H

Legal Aid of Western Missouri
Honorable H. Michael Coburn Community Service Award
Complete the nomination form below
Attach a one page sheet outlining the nominee's accomplishments including: past
awards, achievements and exceptional community service activity, particularly nonBar activity relating to service on behalf of low-income people.
Attach any supporting documents that further describe your nominee's qualifications.
Self-nominations are invited.
Please list three individuals who are familiar with the nominee and his or her
Mail your nominations to The Coburn Award Selection Committee, c/o Legal Aid of Western
Missouri, 1125 Grand Blvd., Suite 1900, Kansas City, Missouri, 64106. Nominations may also
be submitted via e-mail to [email protected] The deadline for receipt of nominations is
5:00p.m. November 13, 2015.
Nominee’s name and professional affiliation:
Nominee's address and phone number:
Person submitting nomination: