APPLICATION FOR NOMINATION
WISCONSIN STATE TELECOMMUNICATIONS ASSOCIATION
HALL OF FAME AWARD/LIFETIME ACHIEVEMENT AWARD

Hall of Fame Award
Lifetime Achievement Award

NAME OF NOMINEE:

ADDRESS:

CITY: STATE: ZIP CODE:

PLACE OF BIRTH:

EMPLOYER:

POSITION:

IF RETIRED, DATE OF RETIREMENT:

IF DECEASED, DATE OF DEATH:

EDUCATION: (Names of schools attended, dates attended, degrees received, plus honorary degrees, if any):


SPOUSE:

DATE OF MARRIAGE (Please include maiden name of wife):

CHILDREN (In order of birth; if daughters are married, include full married name):

NEAREST OF KIN (Living):

Participation in Wisconsin State Telecommunications Association (WSTA), such as offices held, Board of Directors, committees, speeches, seminars, and other activities:


Participation and activites in other telephone associations, such as Wisconsin Locally Owned, USTA, ITPA, OPASTCO, REA Borrowers Association, NTCA:


Civic, political, military, philanthropic activities, etc. (Include offices held and dates:


Non-business directorships, trusteeships, etc. (such as church, hospitals, etc.):


Other affiliations (memberships in commercial, professional, scientific associations, societies, lodges, clubs, etc. (Include offices held, if any, and dates):


Noteworthy special work (not included above, such as articles published,
inventions, books published, and other accomplishments):


Career Summary (Give in chronological order the nominee's business history, with positions, names of companies, locations, dates and facts regarding the specific outstanding service which would justify election to the Hall of Fame or Lifetime Achievement:


SPONSOR NAME:

ADDRESS:

CITY: STATE: ZIP CODE:

PHONE: EMAIL:


WSTA would appreciate it if you would include a photograph of the nominee with this application. You may also include other information and exhibits. Please email this information to Roxanne Dugan.

Deadline for this year's nominations is February 1, 2007 to be considered for those awards given at WSTA's Annual Convention