Please answer all questions:

CANDIDATE'S NAME: _________________________________________________

SCHOOL ADDRESS:___________________________________________________

HOME ADDRESS:_____________________________________________________

SCHOOL PHONE:_________________       FAX:__________________

HOME PHONE:____________________

Present school, position, duties, and years of service.

SCHOOL:__________________________________________________________

POSITION:_________________________________________________________

DUTIES:___________________________________________________________

YEARS OF SERVICE:  (THIS SCHOOL)______

OTHER SCHOOLS__________________________________________________
                                               ( List Schools and number of years)

NAME OF REFERENCE:  ____________________________________________

TITLE: ____________________________________________________________

ADDRESS:_________________________________________________________

Education Preparation ( list colleges attended and degrees received)

School and community involvement (positions of leadership the candidate has held, and the year held).

Professional affiliations (example: ND Traffic Safety Education Association, Inc., NDEA, etc).

Honors and awards received (professional and others).

Nominee's Qualifications (What has the candidate done to upgrade the program of driver and traffic safety education in their school and community.

Provide as much information as you can on additional sheets, attach to this nomination form and return by one week prior to the annual spring conference. Mail completed application one week prior to Spring Conference to: Larry Nagel, HCR1-Box 11, Shields, ND 58569.