Excalibur Nomination Form

Additional comments and supporting documentation may be included on supplemental pages, if
necessary. You may reproduce this form. In order to be considered for judging, form must be legible.
Nomination Forms are due Friday, November 11th at 5p.m.
Completed forms can be mailed or delivered to:
Publisher's Office. Rockford Register Star, 99 E. State St., Rockford, IL 61104.
Please contact Bea Ricotta with any questions at bricotta@rrstar.com or 815.987.1453.

I would like to nominate: First Middle Last
Please enter the nominee's first, middle, and last name
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Please enter the nominee's address information.
Business address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Please enter nominee's business address.
E-mail

Please enter nominee's e-mail address.
Home phone - (###) - ### ####
Please enter nominee's home phone.
Business phone - (###) - ### ####
please enter nominee's business phone.
Major constructive achievements

Please enter all achievements for nominee. Date: Achievement
Public offices and volunteer activities

Please enter all public offices held and volunteer activities participated in.
Membership in religious, fraternal, business or social groups and offices held

Please enter all Membership in religious, fraternal, business or social groups and offices held
Nominator First Last
Please enter nominator's name.
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Please enter nominator's address information.
E-mail

Please enter nominator's e-mail address.
Home phone - (###) - ### ####
Please enter nominator's home phone.
Business phone - (###) - ### ####
Please enter nominator's business phone number.