Clean Air Excellence Awards - Entry Form -

Please refer to Application Guidelines for 2020 Awards for details on how to submit projects for consideration. Please use a separate form for each entry. This is a fill-in form, so type your responses. For text fields that are not applicable, please type N/A.

SECTION I. PROJECT CONTACT

Project Name: Project Location: (City and State) City:

State: If Project is Nationwide, please check box: ◻ Organization Responsible for Project: Duration of Project: Start: End:

NOOngoing: ◻ YES

Project Partner(s): Please list all partners that played a role in the nominated project. The listed partners are those organizations you wish to recognize, if the nominated project is selected. Partners may be recognized in the award booklet, acceptance speech, EPA website, and/or award certificate.

SECTION II. PROJECT DETAILS AND DESCRIPTION

Project Submitted by: Title: Organization: Address: Telephone Number: Fax Number: Email:

Please check here if you would like to receive future awards program announcements:

◻ Clean Air Technology ◻ State/Tribal/Local Air Quality Policy Innovations

◻ Community Action ◻ Transportation Efficiency Innovations

◻ Education/Outreach

Gregg Cooke Visionary Award ◻ In addition to one of the categories above, please check the box below if you would like to be considered for the Gregg Cooke Visionary Award. Before checking this box, please read the criteria. If your project qualifies for the Gregg Cooke award, please describe:

Thomas W. Zosel Outstanding Individual Achievement Award ◻ If you are nominating an individual for the Thomas W. Zosel Outstanding Individual Achievement Award, please provide contact information for the nominated person:

Name of Nominated: Organization: Address: Telephone Number: Email:

Award Category

Which award category applies to your entry? (You may select one ONE category.) Please refer to the guidelines for details about the award categories.

Please provide a narrative description of your entry and explain why it should receive a Clean Air Excellence Award. Be sure to address the evaluation criteria for the category applicable to your entry.

Please provide a list of all supporting documentation including titles and format style (e.g., hard copy, PDF, Word, etc.). The supporting information must be relevant to the project that is being nominated.

SECTION III. AWARD CERTIFICATE INFORMATION

If your nomination is selected to receive the Clean Air Excellence Award, please provide certificate information. Please note that award certificates cannot be customized. Only the organization(s) and project title that is listed, will be printed on the certificate.

Organization: Project Title: # of Awards:

SECTION IV. REFERENCES

Reference #1 Name: Title: Organization: Address: Telephone #: Fax #: Email:

Reference #2 Name: Title: Organization: Address: Telephone #: Fax #: Email:

Reference #3 Name: Title: Organization: Address: Telephone #: Fax #: Email:

V. ADDITIONAL INFORMATION

Please provide the following information about your organization’s knowledge of EPA awards program and resources. This information will not preclude your organization from eligibility for a Clean Air Excellence Award.

1. How did you hear about the Clean Air Excellence Awards Program? (Check all that apply.)◻ Website search engine ◻ Website article/Link to awards website ◻ EPA Social Media◻ E-mail distribution ◻ Co-worker/business associate ◻ Other:

2. Have you ever applied for this award? ◻ NO ◻ YES

If yes, when? ___________________________________________________

3. Has your organization ever received a Clean Air Excellence Award? ◻ NO ◻ YES

If yes, please provide name of project, year, category and brief description of winningproject:

4. Has your organization ever received any other award from EPA? ◻ NO ◻ YES

If yes, please provide name of award, year, and brief description the winning project:

5. Has your project ever received funding or support from EPA? ◻ NO ◻ YES

If yes, please explain:

Entries will be accepted electronically at the email address below or mailed/delivered (via U.S. Postal Service or express courier) to the address below. All entries must be sent electronically, delivered or postmarked by __________________________________.

Click Here to Submit Documents

-OR-

Mail entry form and supporting documents to: The Clean Air Excellence Awards Program

ATTN: Catrice Jefferson U.S. EPA, Office of Air and Radiation

Mail Code 6103A, Room 5442-Q (WJC-North) 1200 Pennsylvania Avenue, NW

Washington, D.C. 20460

If you have any questions, please contact Catrice Jefferson at Jefferson.catrice@epa.gov.