Department of Arizona Awards Application Form

Disabled American Veterans

Department of Arizona

Department of Arizona Awards Application Form

Must Be Returned By: April 1, 2018 or sooner

Forms are to be returned to:

DAV Department of Arizona
38 W Dunlap Ave
Phoenix, AZ 85021

Phone 602-678-0333

Fax 602-371-0275

E-Mail:

All nominees must be members or eligible for membership.

Nomination For:

Please check your choice:

Distinguished Service Award / Large Business 200+
Disabled Veteran of the Year Award** / Small Business Less than 200
Department Appreciation Award

Distinguished Service Award = This is the Department’s Top Award nominees must show exceptional service and dedication to the DAV and the Veteran Community. This is a once in a lifetime award.

Disabled Veteran of the Year Award = Nominee must be someone who goes above and beyond in his support of DAV and the Veteran Community (has gone way out of his way to assist veterans). This is a once in a lifetime award. Winner of the Department Disabled Veteran of the Year Award is generally nominated for the National Disabled Veteran of the Year Award the following year. (See Page 4 & 5 for submission for this award)

Department Appreciation Certificate = Nominee should be someone the chapter feels should be recognized for their contributions to the DAV and the Veteran Community.

Nominee Name:______Chapter______

Please type or print, the committee must be able to read this:

Nominees Involvement / Achievements within the DAV and other service organizations:

______

Nominees Involvement / Achievements in the Community:

______

Describe why you think this Veteran/Chapter deserves this award

______

FILL IN THE NEXT SECTION ONLY IF YOU ARE NOMINATING SOMEONE FOR THE DISABLED VETERAN OF THE YEAR AWARD.

Nominee’s Name:______

Work Address:______

Home Address: ______

Phone #______
Work Home Cell

Email ______
Work Home

Date of Birth ____/____/_____ Place of Birth______Marital Status ______

Spouse’s Name:______Children:______

MILITARY SERVICE:

Date: __Enlisted __Drafted __Commissioned ______/______/______Date Separated_____/_____/____

Branch: ______Rank:______

DAV MEMBERSHIP:

Select One: __Life __Annual __Eligible __Not Eligible Chapter______Arizona
Number

Disabilities (attach additional sheet as needed:

1.  Service Connection (Include description of how disabilities were incurred)

2. Non-Service Connected

3. How Nominee overcame handicap(s)

Nominee’s Achievements (attach additional sheet if necessary)

Submitted By:

Name:______
Address:______
Contact Number:______
Signature:______

THIS SECTION IS FOR COMMITTEE USE ONLY:

Committee Comments:

______

Committee Decision:______

Committee Chairman Signature:______

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