Eva Lassman 'Take Action Against Hate' Awards Nomination form

First Name: *

Last Name: *

Affiliated Organization: *

Role or Title (as applies to their work countering hate): *

Email: *

Phone: *

Name of Organization: *

Mailing Address: *

City: *

State: * select... AL AK AZ AR CA CO CT DC DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NH NV NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Other

Please provide if 'Other' was selected:

Zip Code/Postal Code: *

Website: *

Phone: *

How long has the organization been in existence: *

Name of Nominator: *

Email: *

Phone: *

Relationship to nominated individual or organization: *

Tell us about the individual or organization you are nominating. Please provide examples of how the nominee is taking action and building awareness to counter hatred in their local, national, or global community. (300 - 500 words) *

Tell us about the impact of the nominee’s work. What has been the result of their efforts? Please be as specific as possible. (300 - 500 words) *

Please attach a letter of recommendation from an individual who can speak with knowledge about the nominee’s contributions. The letter should include the contact person’s email address and phone number. You also have the option of attaching up to three (3) additional documents or artifacts that demonstrate the nominee’s contributions. Such attachments may include, but are not limited to, media features, writing samples, videos, posters, etc. (Maximum size 10 MB)

You are also welcome to include up to three (3) weblinks that highlight the nominee’s work: