2. Nominations will be accepted throughout the year. The application deadline for a given year will be the first Monday of April.
4. Nominator Information
6. First Name
7. Last Name
9. Phone Number
10. Email
12. Nominee Information
    Nominees must have performed services on behalf of Roseville residents or for Roseville residents
14. Name or Business
16. Address1
18. Address2
20. City
21. State
22. Zip
24. Phone Number
26. Email
28. This recognition program provides our community the opportunity to nominate individuals, groups and organizations for meritorious service in the pursuit and advocacy of human rights. It encompasses Roseville residents and anyone working on behalf of Roseville residents.
30. Describe briefly the nominee’s activity or accomplishment
32. Describe the impact on individuals or groups in the Roseville Community. Consider the number of people affected and the longevity or level of change created.
34. Elaborate on any special qualities (i.e. creativity, resourcefulness, stamina, diplomacy) that the nominee demonstrated in achieving this accomplishment.
36. Did the nominee need to overcome any obstacles or exhibit moral courage in order to pursue his or her goal?
38. Provide the names, telephone numbers and e-mail addresses of 3 individuals who can speak to the nominee’s efforts. This may include the person completing this form.
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40. 1. Receive an email copy of this form.
41. Email address

    This field is not part of the form submission.

42. Submit Submit and Print

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