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2. 
3. Printable Nomination Form
   Nomination Form (PDF)

   If printing this form, please submit nomination, supporting information and any questions to: Ashley Mai, City Clerk, by email: ashley.mai@russellcity.org, phone: (785) 483-6311, or mail to PO Box 112, Russell, KS, 67665.

5. Name
7. Email Address
9. Phone Number
10. Do you wish to remain anonymous?

    1. Yes
    2. No
12. Individual, Business, or Organization Nominated?
14. Nominee's email and phone number:
16. Please submit this application with a narrative below describing the nominee's efforts to make a measurable impact on the community. Please explain how the nominees efforts have made a positive impact. Identify examples that demonstrate the key attributes of community impact. Testimonials from individuals, businesses, other organizations who have benefited from the program are encouraged.
18. Key Attributes of Community Impact:

    • Demonstrated dedication and service in improving the lives of others within our community, showcasing leadership qualities as a role model for others. 

    • Innovative problem-solving and implementation of sustainable solutions that advocate for the greater community and inspire engagement and support. 

    • Commitment to collaborative efforts for nurturing the community's greater good, making notable contributions to its development and growth. 

    • Ensuring inclusivity by actively supporting the entire community. 

    • Displaying unwavering commitment by investing significant time and resources towards the community's continuous development. 

    • Acting selflessly, giving back to the community without expecting anything, guided purely by altruistic motives

20. TIMELINE:

    Nominations must be submitted by the 20th of each month. The Community Impact Award Recipient will be recognized at the regular City Council meeting on the third Tuesday of the following month. For example, a Community Impact Award winner selected from the nominations received on or before January 20, 2024 will be recognized at the February 20, 2024 Council meeting. The Community Impact Award winner selected from the nominations received on or before February 20, 2024 will be recognized at the March 19, 2024 Council meeting. One recipient will be awarded each month. 

22. Sponsored By:
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28. 1. Receive an email copy of this form.
29. Email address

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