Electrical/Instrumentation Person of the Year
CORBS 2011
ELECTRICAL/INSTRUMENTATION PERSON OF THE YEAR
NOMINATION FORM
Date:
Name of Nominee:
Nominee’s Address
Work Phone: () Home Phone: ()
Employed By:
Mailing Address:
Physical Address:
Supervisor’s Name:
Supervisor’s Phone:()
Nominee’s Title:
Number of years in field:Years at this Agency:
Type of Plant
Design Flow:MGDActual Flow:MGD
CORBS MemberYesNoCWEA MemberYesNo
Nominee’s Certifications (give sponsoring agency, discipline, grade level, and date received):
Nominee’s Educational Background or any Applicable Work Experience:(give degrees, college, and date received):
OPTIONAL: Any other comments regarding nominee's qualifications.
Examples: Accomplishments in quality control, efforts in the area of safety, public relations work, educational development (short schools, seminars, conferences, etc.)
CORBS 2011
PRETREATMENT, POLLUTION PREVENTION AND STORM WATER PERSON OF THE YEAR
NOMINATION FORM
Date:
Name of Nominee:
Nominee’s Address:
Work Phone: ()Home Phone: ()
Employed By:
Person Making Nomination Phone: ()
Number of years in field:Years at this Agency:
Design Flow:MGDActual Flow:MGD
CORBS Member:YesNoCWEA Member:YesNo
LIST NOMINEE’S JOB POSITION AND RESPONSIBILITIES:
Nominee’s Education and Certifications (give sponsoring agency, discipline, grade level, and date received):
Nominee’s Educational Background or any Applicable Work Experience:(give degrees, college, and date received):
OPTIONAL: Any other comments regarding nominee's qualifications.
CORBS 2011
MECHANICAL TECHNICIAN OF THE YEAR
NOMINATION FORM
Date:
Name of Nominee:
Nominee’s Address:Work Phone: ()Home Phone: ()
Employed By:
Mailing Address:
Physical Address:
Supervisor’s Name:
Supervisor’s Phone: ()
Nominee’s Title:
Number of years in field:Years at this Agency:
Type of Plant
Design Flow:MGDActual Flow:MGD
CORBS Member:YesNoCWEA Member:YesNo
Nominee’s Certifications (give sponsoring agency, discipline, grade level, and date received):
Nominee’s Educational Background or any Applicable Work Experience:(give degrees, college, and date received):
Does the nominee have maintenance specialities?
OPTIONAL: Any other comments regarding nominee's qualifications.
Examples: Accomplishments in quality control, efforts in the area of safety, public relations work, educational development (short schools, seminars, conferences, etc.)
CORBS 2011
LABORATORY PERSON OF THE YEAR
NOMINATION FORM
Date:
Name of Nominee:
Nominee’s Address:
Work Phone: ()Home Phone: ()
Employed By:
Mailing Address:
Physical Address:
Supervisor’s Name:
Supervisor’s Phone:()
Nominee’s Title:
Number of years in field:Years at this Agency:
Type of Plant
Design Flow:MGDActual Flow:MGD
CORBS Member:YesNoCWEA Member: YesNo
Nominee’s Certifications (give sponsoring agency, discipline, grade level, and date received):
Nominee’s Educational Background or any Applicable Work Experience:(give degrees, college, and date received):
OPTIONAL: Any other comments regarding nominee's qualifications.
Examples: Accomplishments in quality control, efforts in the area of safety, public relations work, educational development (short schools, seminars, conferences, etc.)
CORBS 2011
PUBLIC EDUCATION PROGRAMOF THE YEAR
NOMINATION FORM
I.NOMINEE INFORMATION
Note: If nomination is for a committee or group, please include information for each member on a separate attachment (or photocopy) for this section.
A.Name of Applicant:
Address:
Phone: () Fax: ()
B.Employer:
Job Title:
- Educational Background or Training:
- Role in Public Education Activities:
- Other Pertinent Information:
- Local Section Member (required):YesNo
- CWEA Member:YesNo
IIPROGRAM INFORMATION
A.Name of program project:
B.Location:
C.Budget:
D.If joint program list other member/agencies and their contributions to the program, using an additional sheet if necessary:
E.If volunteers were used, estimate the hours invested:
F.Dates of program implementation:
IIIPROGRAM DESCRIPTION
A.Program Objectives:
B.Methods Used:
C.Target Audience(s)
D.Problem or issue which was addressed:
E.Material used or created (attach examples):
- If volunteers were used, how were they recruited:
- Obstacles overcome:
- Timing or other constraints:
- Other Issues:
IVPROGRAM RESULTS
Describe the results of the program as related to the stated objectives. Quantify results (number of brochures distributed, number of people in attendance, etc.) or attach news clippings or other documentation of the program.
CORBS 2011
APPLICATION FOR PLANT OF THE YEAR AWARD
Date:
Name of Plant:
Plant Classification: IIIIII IV V
Plant Address:
Name of City or District Manager:
Person to Contact:
Phone:()
Number of Employees: OperLabMaint: Other
Number of Certified Personnel: OperLab Maint Other
Laboratory: YesNoCertified: YesNo
Are records available for Safety: YesNo
Discharge requirement:Violations Maint.
Lab(if yes, please have available at them of inspection)
Number of CORBS members: Number of CWEA members:
Name Title
CORBS 2011
SAFETY PROGRAM OF THE YEAR AWARD
NOMINATION FORM
BACKGROUND INFORMATION:
Agency:
Number of employees: Population Served:
Contact Person:
Address:
Phone: ()Fax: ()
HAVE THERE BEEN ANY LOST TIME INJURIES IN THE LAST YEAR? IF SO, PLEASE EXPLAIN:
LIST YOUR SIGNIFICANT SAFETY ACCOMPLISHMENTS OR IMPROVEMENTS OVER THE LAST YEAR:
CORBS 2011
SUPERVISOR OF THE YEAR A WARD
NOMINATION FORM
Date:
Name of Nominee:
Nominee’s Address:
Work Phone: ()Home Phone: ()
Employed By:
Mailing Address:
Physical Address:
Person Making Nomination:
Phone:()
Nominee’s Title:
Number of years in field:Years at this Agency:
Type of Plant
Design Flow:MGDActual Flow:MGD
CORBS Member:YesNoCWEA Member:YesNo
Nominee’s Certifications (give sponsoring agency, discipline, grade level, and date received):
Nominee’s Educational Background or any Applicable Work Experience:(give degrees, college, and date received):
OPTIONAL: Any other comments regarding nominee's qualifications.
Examples: Accomplishments in quality control, efforts in the area of safety, public relations work, educational development (short schools, seminars, conferences, etc.)
CORBS 2011
PLANT OPERATOR PERSON OF THE YEAR
NOMINATION FORM
Date:
Name of Nominee:
Nominee’s Address:
Work Phone: ()Home Phone: ()
Employed By:
Mailing Address:
Physical Address:
Supervisor’s Name:
Supervisor’s Phone:()
Nominee’s Title:
Number of years in field:Years at this Agency:
Type of Plant
Design Flow:MGDActual Flow:MGD
CORBS Member:YesNoCWEA Member: YesNo
Nominee’s Certifications (give sponsoring agency, discipline, grade level, and date received):
Nominee’s Educational Background or any Applicable Work Experience:(give degrees, college, and date received):
OPTIONAL: Any other comments regarding nominee's qualifications.
Examples: Accomplishments in quality control, efforts in the area of safety, public relations work, educational development (short schools, seminars, conferences, etc.)
CORBS 2011
APPLICATION FOR COLLECTION SYSTEM OF THE YEAR AWARD
Date:
Name of Agency:
Size of Collection System: miles
Agency Address:
Name of City or District Manager:
Names of Superintendent:
Person to Contact:
Present Agency Flow: MGD Design:MGD
Range of pipe sizes: inches to inches
Number of pumping stations: Population Served
# Employees: # CORBS members: # CWEA members:
Number of Certified Personnel: Grade I Grade II Grade III Grade IV
Annual Budget: Operating: $ Capital Improvements: $
Annual Service Charge (average residence): $
Number of sewer overflows in the last 12 months (> 1000 gallons)
Number of stoppages in the last 12 Months:
Do you have a pipeline replacement program? If yes, please explain:
Describe any unique challenges that your agency has faced and describe how you addressed those challenges. Use additional sheets if necessary.
List your agency’s accomplishments for the last 12 months. Use additional sheets if necessary.
Name Title
CORBS 2011
COLLECTION SYSTEM PERSON OF THE YEAR
NOMINATION FORM
Date:
Name of Nominee:
Nominee’s Address:
Work Phone: ()Home Phone: ()
Employed By:
Mailing Address:
Physical Address:
Supervisor’s Name:
Supervisor’s Phone:()
Nominee’s Title:
Number of years in field:Years at this Agency:
Type of Plant
Design Flow:MGDActual Flow:MGD
CORBS Member:YesNoCWEA Member: YesNo
Nominee’s Certifications (give sponsoring agency, discipline, grade level, and date received):
Nominee’s Educational Background or any Applicable Work Experience:(give degrees, college, and date received):
OPTIONAL: Any other comments regarding nominee's qualifications.
Examples: Accomplishments in quality control, efforts in the area of safety, public relations work, educational development (short schools, seminars, conferences, etc.)