CWEA Nomination Form
5S
Select Society of Sanitary Sludge Shovelers
5S_Nomination_Form.docx
CWEA Nomination Form
5S
Select Society of Sanitary Sludge Shovelers
Who is eligible? CWEA members who have contributed an excess of five (5) years to the wastewater collection, design and operations objectives of CWEA are eligible for membership in the 5S society. Service may have been completed as a CWEA or Local Section officer, Committee member or faithful volunteer at the local, regional, state or even national level.
How are 5S members selected? Nominations are accepted from individuals as well as Local Sections and CWEA committees. A select committee of Sludge Shovelers evaluates all the supporting documentation for each nominee. Only a few are selected each year. Selection is made solely on merit — it is not a popularity contest. Note that scoring weight in percentages is indicated below.
To nominate a deserving person, use this nomination form. The intent is for the nominator to interview the nominee and fill in the information requested during the interview. Once completed, the form can be saved and emailed directly to the email address below. In addition, please submit a digital photo (jpg format) of the nominee, suitable for use in an awards presentation. File size must be at least 250 kb.
DEADLINE EXTENDED: NOMINATIONS MUST BE RECEIVED BY MARCH 27, 2017
I nominatefor membership in the Select Society of Sanitary Sludge Shovelers. A resume detailing the nominee’s dedicated volunteer commitment to CWEA-related activities is attached.
NOMINEE:
Name of Nominee
Title
Employer
Phone
NOMINATOR:
Submitted by
Employer
Address
Daytime Phone
SEND NOMINATION TO:Patrick Griffith at
5-S NOMINEE INTERVIEW FORM
Membership Information
CWEA Member: Enter Yes or No
CWEA Member Number: Enter Member Number
CWEA Member Since Enter Year first became a member
Local Section Membership:
WEF Member: Enter Yes or No
WEF Member Number: Enter WEF Member Number
Certification Information
List CWEA Technical Certification Program Certificates Held (indicate discipline, grade level, and date obtained):
______
Local Section Activities (20.6%)
Local Section Board Member: Enter Yes or No
List Positions and dates:
______
Local Section Committee Member:Enter Yes or No
List Committees, positions held, responsibilities, and dates:
______
Other Local Section Activities, including speaker, trainer, exhibitor, etc. List activities and dates:
______
Regional Committee Activities (20.6%)
Regional (North/South) Committee Member: Enter Yes or No
List Positions and dates:
______
Other Regional Committee Member: Enter Yes or No
List Committees, positions held, responsibilities, and dates:
______
Other Regional Activities Activities, including speaker, trainer, exhibitor, etc. List activities and dates:
______
State Level Activities (20.6%)
CWEA Board Member: Enter Yes or No
List Positions and Dates:
______
State Committee Member: Enter Yes or No
List Committees, Positions Held, Responsibilities, Activities, and Dates:
______
Other State Level Contributions, including speaker, trainer, author, exhibitor, etc.: List activities and dates
______
National Level Activities (14.7%)
WEF Committee Member: Enter Yes or No
List Committees, Positions Held, Responsibilities, and Dates
______
Other National Level Activities, including speaker, trainer, author, exhibitor, etc. List activities and dates
______
Awards (8.8%)
Please list any awards received at local, regional, state, or national level. List award and date received.
______
Other Information (14.7%)
Please list any other relevant information not covered above. List activity, dates, etc. For the Nominator – As you think about other valuable information, feel free to move it to sections listed above if applicable.
______
Humorous Information About Nominee
Please provide 2-3 humorous or offbeat items about the nominee. This information is intended to be used by the Committee in the Induction Ceremony at the Annual Conference.
______
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