Community Access Awards Form

Indy Bird Logo

Independence, Inc.
Independent Living Resource Center
Serving People with Disabilities Since 1978

Nomination Form - Independence, Inc. - Community Access Awards

Name of Nominee: ___________________________________________________

Title/Organization (if applicable): _________________________________________

Address: ___________________________________________________________

Telephone: ________________________________

Category: _____ Individual / _____ Business / _____ Organization
_____ Roger Williams Community Access Award

Please indicate below or attach a statement explaining why you feel this nominee should be considered for the Community Access Award.

________________________________________________________________

Your Name: ______________________________________________________
Title/Organization (if applicable): ______________________________________________________

Address: ________________________________________________________________

Telephone: ________________________________

This form may be copied if you wish to make more than one nomination. Send completed forms by June 30, 2000 to: Independence, Inc., 2001 Haskell Ave., Lawrence, KS 66046 or fax to 785/841-0333.

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