13th Employment Supports Symposium:
A Pennsylvania Employment Conference 
For People With Disabilities
Spreading Employment 1st
Exemplary Employer Award Nomination Form

Name of Person Being Nominated:  ________________________________________________________________
Title of Nominee:  ____________________________________________________________________________
Business Name & Address:  _____________________________________________________________________
_____________________________________________________ Phone:  ______________________________
Email Address:  ______________________________________________________________________________
Name of Person(s) Nominating the Employer:  ________________________________________________________
Title of Person(s) Nominating Employer:  ____________________________________________________________
Organization Name & Address:  _________________________________________________________________
_____________________________________________________ Phone:  ______________________________
Email Address(s) of person(s) nominating employer:  ___________________________________________________
How long has the employee with a disability been employed by this employer:_______
What are the Employee’s job responsibilities: ___________________________________________________________

Nominations must be submitted in a narrative format. Your nomination will be scored on the following areas. Please make sure to cover each one in order for your employer to be considered.

* Why is the employer being nominated for an award
* How has the employer utilized Job accommodations
* Has the employer used job carving/job creating/customized employment and how.
* How has this employer fostered natural supports and assisted the employee to fit in with coworkers and the culture of the work site
It is strongly recommended that the nomination be typed.
The deadline for nomination submission is March 02, 2011.  Please send your forms to:

Employer Awards Nomination Committee, 
Networks for Training and Development, Inc.
1220 Valley Forge Road, Unit 17, PO Box 206, Valley Forge, PA 19481-0206

You may also:
Fax completed forms to 610-935-6497 
Questions: please call Tracy Katz at 215-264-2833