13th Employment Supports Symposium:
A Pennsylvania Employment Conference 
For People With Disabilities
Spreading Employment 1st!
The Octavia Green Dream Job Award

Name of Self Advocate Being Nominated:  ______________________________________________________________
Job Title:  ____________________________________________________________________________
Business Name & Address:  _____________________________________________________________________
_____________________________________________________ Phone:  ______________________________
Email Address:  ______________________________________________________________________________
Name of Person(s) Nominating the Self Advocate:  ________________________________________________________
Title of Person(s) Nominating the Self Advocate:__________________________________________________________
Organization Name & Address:  _________________________________________________________________
_____________________________________________________ Phone:  ______________________________
Email Address(s) of person(s) nominating the Self Advocate:  _______________________________________________
How long has the Self Advocate been employed by this employer:_______
What are the Self Advocate’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 Self Advocate being nominated for an award
* What makes this the Self Advocate’s dream job

It is strongly recommended that the nomination be typed.
The deadline for nomination submission is March 02, 2012.  Please send your forms to:

Octavia Green Dream Job Award 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 Joe Murphy at: 215-251-6168