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2. Community Builder Nomination Form 2023
4. Nominator Information
6. Full Name*
8. Street Address*
10. City*
11. State*
12. Zip Code*
14. Phone Number*
15. Email Address*
17. Is the nominee aware of this nomination?*

    1. Yes
    2. No
19. I understand that for a nomination to be considered for the same year, nominations must be submitted no later than March 31 for recognition in June. Nominations received after March 31 will be considered for the following year.*

    1. Yes
    2. No
21. Nominee Information
23. Full Name of Nominee (Individual, Group, Organization, or Business)*
25. Address*
27. City*
28. State*
29. Zip Code*
31. Phone Number*
32. Email Address*
34. Please describe the nominee’s activities, accomplishments, or contributions to Victoria.*
36. Please describe how the nominee has positively impacted the community.*
38. References
40. Reference #1 Full Name*
42. Reference #1 Phone Number*
43. Reference #1 Email Address*
45. Reference #2 Full Name*
47. Reference #2 Phone Number*
48. Reference #2 Email Address*
50. Documentation
52. Please upload any supporting documents (e.g. letters of reference or support, resumes, media stories, testimonials, etc.)

54. Please note that by submitting your entry, you are granting the City of Victoria approval to use your entry for promotional purposes. Completed entries must be submitted or postmarked by March 31, 2023.

    Electronic submissions are encouraged. Alternatives to submitting via this form are listed below:

    Send via email to: kgrahl@ci.victoria.mn.us

    Send via mail to: City of Victoria, Minnesota
    Attn: Kendra Grahl
    P.O. Box 36
    Victoria, MN 55368

    
    

56. Consent*

    1. I certify that the information submitted is true and accurate to the best of my knowledge.
58. Tennessen Warning

    Please take notice that any data received by the City as the result of submitting this form will be classified as government data pursuant to the Minnesota Government Data Practices Act, Minnesota Statutes Chapter 13. Under the Data Practices Act, some or all of this data is classified as public data, including your name, address, email address, phone number, and other personal information provided by you. Public data is available to anyone requesting it and consists of all data furnished via this Web form. Please be advised that the correspondence will be added to the public record. The purpose and intended use of the information collected through this form is to obtain public input and data in support of City activities and services. You have the right to refuse to submit this form. If you choose not to submit this form, you will need to contact the City by another means if you wish to provide the information collected by the form.

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60. Submit

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