NJAPIE Exemplary Partnership Program Award

EXEMPLARY PARTNERSHIP PROGRAM AWARD
INFORMATION FORM

Step 2 - Complete this information form.
(Information Form in Word format) (Information Form in PDF format)

Program Name: ___________________________________________________________

Nominator's Name: ________________________________________________________

Nominator's Title: _________________________________________________________

Nominator's Address: (Street Address/City/State/Zip Code) _________________________

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Nominator's Telephone Number: (______)_______________________________________

Organization Name: ________________________________________________________

Organization Address: (Street Address/City/State/Zip Code) _________________________

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List of Community Partners: _________________________________________________

_______________________________________________________________________

The nominated program focuses on the following grade level or area: (Please select one)
[ ] Elementary	[ ] Middle/Jr. High School
[ ] High School	[ ] Vocational-Technical School
[ ] Other: ________________________________________________________________

District: _________________________________ County: _________________________

Address: ________________________________________________________________

City/State/Zip: ____________________________________________________________

District Superintendent: _____________________________________________________

District Telephone Number: (______)___________________________________________

Date of Program Initiation: ___________________________________________________