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Lifetime Achievement Award Form for Mail/Fax
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APPLICATION FOR NOMINATION
WISCONSIN STATE TELECOMMUNICATIONS ASSOCIATION
LIFETIME ACHIEVEMENT AWARD

The WSTA Awards Committee prefers candidates for the Lifetime Achievement 
Award that are either retired or 65 years of age.

Please print or type:

Date ____________________________

Name of the Nominee ______________________________________________________
(First) (Middle) (Last)

Address __________________________________________________________________
(City) (State) (Zip)

Place of birth ____________________ Date of Birth ____________________

Employer __________________________ Position _______________________________

If retired, date of retirement _______________________________________________

If deceased, date of death and closest living relative___________________________

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

Spouse _________________________ Date of Marriage _______________________
(Include maiden name of wife
if applicable)

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

Service to WSTA
(20 Points)
Participation in Wis. State Telecommunications Assn. (WSTA), such as offices
held, Board of Directors, committees, speeches, seminars, and other activities:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Service to Other Industry Associations
(20 Points)
Participation and activities in other telephone associations, such as Wisconsin
Locally Owned, USTA, ITPA, OPATSCO, REA Borrowers Association, NTCA:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Leadership Qualities
(20 Points)
1. Civic, political, military, philanthropic activities, etc. (Include offices held
and dates):
________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

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

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

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

Career Summary
Please provide in chronological order the nominee's business history, with
positions, names of companies, locations, and dates. The Awards Committee
would also like to see facts regarding the specific outstanding service, including
achievement in the industry, performance and success of their companies, and
significant contributions to the industry as a whole which would justify election
to the Hall of Fame:

Business history:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Achievements in the Industry:
(30 Points)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Performance and success in their companies:
(20 Points)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Significant contributions to the industry as a whole:
(40 Points)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________

Sponsor _____________________________
(Signature)

Sponsor's Name _____________________________
Address _____________________________

City and State _______________ Zip _________

Phone_________________

We would appreciate it if you would include a photograph of the nominee with
this application. You may also include other information and exhibits. Use
additional pages if needed.

Please forward completed application by February 1, of the current year to:
 
Attention: WSTA Lifetime Achievement Award
Wisconsin State Telecommunications Association
122 West Washington St, Suite 1050
Madison, WI 53703

A form to download is also available on the WSTA website at: https://wsta.site-ym.com/?page=HOFLifetimeForm

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