Name/address/phone number of person to be nominated (must reside in Rockland):

_____________________

_____________________

_____________________


Nominated by: ______________________________ Ph. # _________________
(may self-nominate)

Brief biography of nominee: (attach)


Poetry experience: include here (attach) any work the nominee has done to foster
poetry, including workshops, presentations, awards, publications, etc.



Reason for nominating: (BE BRIEF)











OR.... Poet’s “mission statement” (if self-nominating)