NATIONAL ASSOCIATION OF REALTORS

DISTINGUISHED SERVICE AWARD - NOMINATION FORM A high quality electronic photograph of the nominee is MANDATORY. All information must be completed in this format and resumes may be attached in addition to the completed nomination form. Only nominations submitted in this format will be considered. The Nominee MUST sign off on this form indicating that he/she has reviewed and approve the final submission. Please provide a copy of the final application to the Nominee for their records. Nominee Name: Full Date of Birth: How long has the nominee been an active member? Office Address: Home Address: Email: Cell Phone (Required): Office Telephone: Home Phone:

What Board does the Nominee hold membership in? Nominated By: State or Local Board Name: State or Local Board Address: Telephone: Date Submitted: Is the nominee still an active, participating member of the local & state associations? (Please circle) LOCAL BOARD/ASSOCIATION: Yes No The candidate holds a valid real estate license in the State of (If the nominee does not hold such a license, he or she is not eligible for this award.) STATE ASSOCIATION: Yes No

REQUIRED SIGNATURES As the DSA Nominee, by signing below I hereby certify that I have thoroughly read and approve these documents for final submission:
DSA Candidate

Local Board / Assoc President or AE

Please mail or e-mail all completed documents to:

State Assoc President or AE

nd

Alisa Thompson, c/o Executive Offices (Postmark no later than Monday, April 2 , 2012) NATIONAL ASSOCIATION OF REALTORS 430 North Michigan Avenue | Chicago, Illinois 60611-4087 NARDSA@realtors.org | Office: 312-329-8415