MO-CASE Distinguished Service Award Nomination Form

Name:

Address:

City, State, Zip

Phone

Email

Are you a MO-CASE Supporter?

Are you a CEC Member? If yes, list division memberships

Current School District/Employer

How long in current position?

List prior years of experience.

Describe the folowing: Professional Memberships and Activities

Describe the following: Innovation and Outstanding Contributions to Special Education

Describe the following: Impact on Administrator Preparation and/or Quality of Services to Exceptional Children

Describe the following: Additional education-related and/or community activities (e.g. research, teaching, publication, administration, community service)

Nominated by: Name, Phone, Email

Additional Documents Needed

Please mail the following to MO-CASE, 1028 S. Bishop, PMB 306, Rolla, MO  65401 or FAX to 573-426-2767.  They must be received by May 1st.

**Professional Resume
**Three letters of recommendation including one from your current employer/supervisor