RETURN FORM TO: Central Chapter, PSHF
P.O. Box 1397 Lebanon, PA  17042

Nominated for - circle one          A. Induction
B. Community Service Award
C. Courageous Athlete
D. Other - describe

Nominee Information
(This form must be typed or printed.
Part I: PERSONAL INFORMATION of NOMINEE - Check One: Living ( ) Deceased( )

A) Full Name ______________________________________________________    
B) Address ________________________________________________________    
C) City ___________________________________ State ____ Zip ________    
D) Telephone (include area code) ________________________
E) E-mail address _______________________________________

Part II: ONLY for DECEASED NOMINEES:
A) Representative for Nominee ________________________________________
B) Relation (wife, son/daughter, nephew, etc.) _______________________
C) Telephone (include area code) _____________________________

Part III: INFORMATION about the NOMINEE - Attach a glossy photograph; School, College, Team, Years, Achievements, Records, Honors, Player, Coach-years, etc.) NOT TO EXCEED 75 WORDS - list the most important facts first.

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Part IV:  I, the undersigned, hereby certify to the best of my knowledge, the personal and biographical information on this form is correct.

 

Printed Name of Inductee/Deceased Representative __________________________________________________________________________________________
Inductee/Deceased Representative Signature _____________________________________________________________________Date ______________________

Part V: CRITERIA for submitting the NOMINEE for induction.

A) Must have met one (1) of the following requirements:
1) Reached their 40th birthday.
2) Participated in the sport/position at least fifteen (15) years.
*Participation is defined, and interpreted on a case by case basis, as having competed, coached, administered, etc., in an athletic endeavor and probably had that participation eclipse its highest level of achievement.
3) Been retired from the sport/position at least two (2) years.
4) Minimum of one (1) year is requirement for deceased nominee.

B) Must attend Annual Induction Ceremonial if selected/elected.

Part VI: The Central Chapter has priority nominating rights from the following geographical areas:
A) Lebanon County
B) Hershey
C) Tulpehocken Area
D) Robesonia-Womelsdorf Area
We may nominate individuals from outside this geographic area. We must, however, afford courtesy coordination with other chapters.

Part VII; This form submitted by:
Member Name ____________________________________________________________
Address ________________________________________________________________
City_______________________________________ State ____ Zip Code _________
Telephone _________________ E-Mail ______________________ Date Submitted _____     
Revised 9/11