2. Name of Nominee:
4. Nominee's Organization/Company (if applicable):
6. Nominee's Phone Number:
7. Nominee's Email Address:
9. Address1
11. City
12. State
13. Zip
15. Category: (Check One)

    1. Business
    2. Education
    3. Individual
    4. Professional
    5. City Employee
    6. Organization
    7. Veteran
    8. Youth
    9. Honorary Citizen (Non-Resident of Rock Island)
17. Please list significant contribution(s) the nominee has made to the City of Rock Island with specific attention to their involvement within the past year or recent years.
19. Nominated by:
20. Would like to remain anonymous?

    1. Yes
    2. No
22. Resident/Organization/Company:
23. Phone Number:
25. Email Address:
27. Optional: Additional Reference

    Please list contact information for an additional reference you would like us to contact regarding your nomination.

29. If you have any questions, please call the City Clerk's office at 309-732-2012.

Leave This Blank:


31. 1. Receive an email copy of this form.
32. Email address

    This field is not part of the form submission.

33. Submit Submit and Print

* indicates a required field