Nominee information (Please share as much information as possible):

1. First Name *
2. Last Name *
3. Address
4. City
5. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
6. ZIP Code
7. Email
8. Home Phone
   xxx-xxx-xxxx
9. Work Phone
   xxx-xxx-xxxx
10. Mobile Phone
    xxx-xxx-xxxx

Scouting Information (Please share as much infomation as possible, If applicable)

1. Current Adult Scouting Position Advisory Council Assistant Council Commissioner Assistant Cubmaster Assistant Den Leader Assistant District Commissioner Assistant Scoutmaster Assistant Treasurer Assistant Varsity Scout Coach Assistant Webelos Den Leader Associate Member Camp Staff Chartered Organization Representative College Scout Reserve Committee Chairman Committee Member Council Commissioner Council Committee Member Council Member at Large Council President Crew Advisor Crew Associate Advisor Cubmaster Den Leader District Activities Committee Chairman District Activities Committee Member District Advancement Committee Chairman District Advancement Committee Member District Camping Committee Chairman District Camping Committee Member District Chairman District Commissioner District Committee Chairman District Committee Member District Community Service/Good Turn Chairman District Community Service/Good Turn Committee Member District Finance Committee Chairman District Finance Committee Member District FOS Committee Chairman District FOS Committee Member District FOS Community Chairman District FOS Community Member District FOS Family Chairman District FOS Family Member District FOS Leadership Chairman District FOS Leadership Member District Health & Safety Committee Chairman District Health & Safety Committee Member District Member at Large District Membership Committee Chairman District Membership Committee Member District Public Relations Committee Chairman District Public Relations Committee Member District Training Committee Chairman District Training Committee Member District Vice Chairman Executive Board Member Honorary Member Leader of Eleven Yr Old Scouts (Formerly Blazer Leader) Lone Cub Scout Friend and Counselor Lone Scout Friend and Counselor Mate Merit Badge Counselor National Committee Advisory Council Member National Committee Chairman National Committee Consultant National Committee Executive Board Member National Committee Honorary Member National Committee Life Member National Committee Member-At-Large Neighborhood Chairman Neighborhood Committee Pack Trainer Regional Advisory Council Regional Area Commissioner Regional Area President Regional Area Vice President Regional Chairman Regional Commissioner Regional Committee Member Regional Executive Board Regional Honorary Member Regional President Regional Vice President Roundtable Commissioner Roundtable Staff Scout Alumnus Scout Reserve Scout Supplier Scoutmaster Skipper test Tiger Cub Den Leader Treasurer Unit Commissioner Varsity Scout Coach Vice President Webelos Den Leader
2. Approximate tenure in Scouting (in years)
3. Unit (Pack, Troop, Team, Post or Crew)
4. District
5. Council Name Abraham Lincoln Council Alabama-Florida Council Alameda Council Alamo Area Council Alapaha Area Council Allegheny Highlands Council Allohak Aloha Council BSA Andrew Jackson Council Annawon Council Anthony Wayne Area Arbuckle Area Council Atlanta Area Council BAY-LAKES COUNCIL Baden-Powell Council Baltimore Area Council Bay Area Council Black Hills Area Council Black Swamp Area Council Black Warrior Council Blackhawk Area Blue Grass Council Blue Mountain Council Blue Ridge Council Blue Ridge Mtns Council Blue Water Boston Minuteman Council Buckeye Council Bucks County Council Buckskin Bucktail Council Buffalo Trace Buffalo Trail Council Burlington County Council, B.S.A Caddo Area Council Calcasieu Area Council California Inland Empire Council Calumet Council Cape Cod and Islands Council Cape Fear Council Capitol Area Council Cascade Pacific Council Catalina Council Central Florida Council Central Georgia Council Central Minnesota Central New Jersey Council Inc Central North Carolina Council Central Wyoming Council Chattahoochee Council Chehaw Council Cherokee Area Council Cherokee Area Council #469 Chester County Council Chicago Area Council, BSA Chickasaw Council Chief Cornplanter Council, BSA Chief Okemos Chief Seattle Council Chippewa Valley Council Choctaw Area Council Cimarron Council Circle Ten Council Coastal Carolina Council Coastal Empire Council Colonial Virginia Council Columbia-Montour Concho Valley Council Connecticut Rivers Council Connecticut Yankee Council BSA Conquistador Council Cornhusker Council Coronado Area Council Cradle Of Liberty Council Crater Lake Council Crossroads Of America Dan Beard Council, BSA Daniel Boone Council Daniel Webster Council, BSA De Soto Area Council Del Mar Va Denver Area Council Des Plaines Valley Co Direct Service East Carolina Council East Texas Area Council Erie Shores Council Evangeline Area Far East Council Five Rivers Council, Inc. Flint River Council French Creek Council Gamehaven Gateway Area Georgia-Carolina Gerald R Ford Council Glaciers Edge Council Golden Empire Council Golden Spread Council Grand Canyon Council Grand Columbia Council Grand Teton Council Great Alaska Council Great Lakes Council Great Rivers Council Great Salt Lake Council Great Sauk Trail Great Smoky Mountain Council Great Southwest Council Great Trail Greater Alabama Council Greater Cleveland Greater New York Councils, BSA Greater Niagara Frontier Council Greater Pittsburgh Council Greater St. Louis Area Council Greater Western Reserve Greater Yosemite Council Green Mountain Greenwich Gulf Coast Council Gulf Ridge Council Gulf Stream Council Hawk Mountain Hawkeye Area Council Heart Of Ohio Council Heart of America Council Heart of Virginia Council Hiawatha Seaway Council Hiawathaland Hoosier Trails Council #145 Housatonic Hudson Valley Council Illowa Council Indian Nations Council Indian Waters Council Inland Northwest Council Iroquois Trail Council Istrouma Area Council Jayhawk Area Council Jersey Shore Council Juniata Valley Council Katahdin Area Council Keystone Area Council Knox Trail Council La Salle Council Lake Huron Area Las Vegas Area Council Last Frontier Council Lewis & Clark Council Lincoln Heritage Council Lincoln Trails Council Long Beach Area Council Longhorn Council Longs Peak Council Los Angeles Area Council Los Padres Council Louisiana Purchase Council Marin Council Mason Dixon Council Maui County Council Mecklenburg County Council Miami Valley Council Mid Iowa Council Mid-America Council Middle Tennessee Council Midnight Sun Council Milwaukee County Minsi Trails Council Mississippi Valley Council 141 Mobile Area Council-BSA Mohegan Council Monmouth Council, BSA Montana Council Monterey Bay Area Council Moraine Trails Council Mount Baker Council, BSA Mountaineer Area Mt Diablo-Silverado Council Muskingum Valley Council, BSA Narragansett Council, BSA Nashua Valley Council National Capital Area Council NeTseO Trails Council Nevada Area Council North Florida Council Northeast Georgia Council Northeast Illinois Northeast Iowa Council Northeastern Pennsylvania Council Northern Lights Council Northern New Jersey Council, BSA Northern Star Council Northwest Georgia Council Northwest Suburban Northwest Texas Council Norwela Council Occoneechee Ohio River Valley Council Okefenokee Area Council Old Colony Council Old Hickory Council Old North State Council Orange County Council Ore-Ida Council 106 - BSA Oregon Trail Council Otschodela Council Ouachita Area Council Overland Trails Ozarks Trails Council Pacific Harbors Council, BSA Pacific Skyline Council Palmetto Council Patriots Path Council Pee Dee Area Council Penn's Woods Council Pennsylvania Dutch Council Piedmont Council Piedmont Council Pikes Peak Council Pine Burr Area Council Pine Tree Council Pony Express Council Potawatomi Area Council Potomac Prairielands Puerto Rico Council Pushmataha Area Council Quapaw Area Council Quivira Council, BSA Rainbow Council Redwood Empire Council Revolutionary Trails Council Rio Grande Council Rip Van Winkle Council Rocky Mountain Council Sagamore Council Sam Houston Area Council Samoset Council, BSA San Diego Imperial Council San Francisco Bay Area Council San Gabriel Valley Council Santa Clara County Council Santa Fe Trail Council Scenic Trails Council, BSA Seneca Waterways Sequoia Council Sequoyah Council Shawnee Trails Council Shenandoah Area Council Simon Kenton Council Sioux Council Snake River Council South Florida Council South Plains Council South Texas Council Southeast Louisiana Council Southeast Wisconsin Council #634 Southern New Jersey Council Southern Sierra Council Southwest Florida Council Southwest Michigan Council Stonewall Jackson Council Suffolk County Council, Inc Susquehanna Council Suwannee River Area Council Tall Pine Council BSA Tecumseh Texas Trails Council Theodore Roosevelt Council Three Fires Council Three Rivers Council Tidewater Council Transatlantic Council, BSA Trapper Trails Tri State Area Tukabatchee Area Council Tuscarora Council Twin Rivers Council Twin Valley Utah National Parks Ventura County Council Verdugo Hills Council Virgin Islands Council Voyageurs Area W D Boyce W.L.A.C.C. West Central Florida Council West Tennessee Area Council Westark Area Council Westchester Putnam Western Colorado Council Western Massachusetts Council Westmoreland Fayette Winnebago Council, BSA Yankee Clipper Council Yocona Area Council York-Adams Area Council Yucca Council
6. Council City and State Abilene, TX Akron, OH Alameda, CA Albany, GA Albany, NY Albemarle, NC Albuquerque, NM Amarillo, TX Anchorage, AK Ann Arbor, MI Apopka, FL Appleton, WI Ardmore, OK Asheville, NC Ashland, OH Atlanta, GA Auburn, MI Auburn, NY Augusta, GA Austin, TX Bakersfield, CA Baltimore, MD Bangor, ME Bartlesville, OK Batavia, NY Baton Rouge, LA Beaumont, TX Belleville, IL Bethesda, MD Binghamton, NY Birmingham, AL Bloomington, IN Bloomsburg, PA Boise, ID Boston, MA Buffalo, NY Butler PA Camarillo, CA Canton, MA Canton, OH Casper, WY Cedar Rapids, IA Central Point, OR Champaign, IL Charleston, SC Charleston, WV Charlotte, NC Chattanooga, TN Chicago, IL Chicopee, MA Cincinnati, OH Cleveland, OH Colorado Springs, CO Columbia, MO Columbia, SC Columbus, GA Columbus, MS Columbus, OH Corpus Christi, TX Cumberland, MD Dallas, TX Dalton, MA Davenport, IA Dayton, OH Decatur, IL Denver, CO Derby, CT Des Moines, IA Detroit, MI Dothan, AL Doylestown, PA Du Bois, PA Dubuque, IA East Hartford, CT Eau Claire, WI Ebensburg, PA El Dorado, AR El Paso, TX Enid, OK Erie, PA Eugene, OR Evansville, IN Everett, WA Fairbanks, AK Fairmont, WV Falconer, NY Fargo, ND Findlay, OH Flint, MI Florence, SC Florham Park, NJ Fort Myers, FL Fort Smith, AR Fort Wayne, IN Foster City, CA Framingham, MA Fresno, CA Galveston, TX Garden City, KS Gastonia, NC Geneva, NY Glendale, CA Goldsboro, NC Grand Island, NE Grand Junction, CO Grand Rapids, MI Great Falls, MT Greeley, CO Greensboro, NC Greensburg, PA Greenville, SC Greenwich, CT Griffin, GA Hagerstown, MD Harlingen, TX Hattiesburg, MS Haverhill, MA Hawthorne, NY Hermantown, MN Highland Park, IL Honolulu, HI Horseheads, NY Hot Springs, AR Houston, TX Huntington, WV Hurst, TX Idaho Falls, ID Indianapolis, IN Irving, TX Jackson, MS Jackson, TN Jacksonville, FL Jefferson, GA Johnson City, TN Kalamazoo, MI Kansas City, MO Kennewick, WA Kingston, NY Kinston, NC Knoxville, TN Kokomo, IN La Crosse, WI La Grange, IL Lafayette, LA Lake Charles, LA Lancaster, MA Lancaster, PA Lansing, MI Las Vegas, NV Lehigh Valley, PA Lexington, KY Little Rock, AR Long Beach, CA Los Angeles, CA Louisville, KY Lubbock, TX Macon, GA Madison, WI Manchester, NH Mankato, MN Mannheim, Germany Marquette, MI Massapequa, NY Mechanicsburg, PA Medford, NY Memphis, TN Meridian, MS Miami Lakes, FL Midland, TX Milford, CT Millville, NJ Milwaukee, WI Mobile, AL Modesto, CA Monroe, LA Montgomery, AL Moosic, PA Morganville, NJ Morris, IL Mount Prospect, IL Munster, IN Nashville, TN New Orleans, LA New York, NY Newport News, VA Norton, MA Oakland, NJ Ogden, UT Oklahoma City, OK Omaha, NE Oneonta, NY Orem, UT Owensboro, KY Palm Beach Gardens, FL Paris, TX Parkersburg, WV Pasadena, CA Pensacola, FL Peoria, IL Philadelphia, PA Phoenix, AZ Piedmont, CA Pittsburgh, PA Pleasant Hill, CA Pontiac, MI Port Huron, MI Portland, ME Portland, OR Princeton, NJ Providence, RI Pueblo, CO Quincy, IL Racine, WI Raleigh, NC Rancocas, NJ Rapid City, SD Reading, PA Redlands, CA Reedsville, PA Reno, NV Richmond, VA Roanoke, VA Rochester, MN Rochester, NY Rockford, IL Rome, GA Roswell, NM Sacramento, CA Salina, KS Salinas, CA Salisbury Mills, NY Salt Lake City, UT San Angelo, TX San Antonio, TX San Diego, CA San Jose, CA San Juan, PR San Leandro, CA San Rafael, CA Santa Ana, CA Santa Barbara, CA Santa Rosa, CA Sartell, MN Savannah, GA Seattle, WA Seminole, FL Shreveport, LA Sioux Falls, SD South Bend, IN Spartanburg, SC Spokane, WA Springfield, IL Springfield, MO Springfield, OH St Charles, IL St Joseph, MO St Louis, MO St Paul, MN St Thomas, VI Syracuse, NY Tacoma, WA Tallahassee, FL Tampa, FL Texarkana, TX Tokyo, Japan Toledo, OH Toms River, NJ Topeka, KS Traverse City, MI Tucson, AZ Tulsa, OK Tupelo, MS Tuscaloosa, AL Twin Falls, ID Tyler, TX Utica, NY Valdosta, GA Van Nuys, CA Virginia Beach, VA Wailuku, HI Walton, NE Warren, OH Warren, PA Waterbury, VT Waterloo, IA Waukesha, WI Waycross, GA Waynesboro, VA West Chester, PA Weston, WI Wheeling, WV Wichita Falls, TX Wichita, KS Williamsport, PA Wilmington DE Wilmington, NC Winchester, VA Winston-Salem, NC Worcester, MA Yakima, WA Yarmouth Port, MA York, PA Zanesville, OH
7. Region & Area National Council, BSA Northeast Region Northeast - Area 1 Northeast - Area 2 Northeast - Area 3 Northeast - Area 4 Northeast - Area 5 Northeast - Area 6 Northeast -Area 7 Southern Region Southern - Area 1 Southern - Area 2 Southern - Area 3 Southern - Area 4 Southern - Area 5 Southern - Area 6 Southern - Area 7 Southern - Area 9 Southern - Area 10 Central Region Central - Area 1 Central - Area 2 Central - Area 3 Central - Area 4 Central - Area 5 Central - Area 6 Central - Area 7 Western Region Western - Area 1 Western - Area 3 Western - Area 4 Western - Area 5 Western - Area 6 Western - Area 7

Person submitting nomination:

1. Your First Name *
2. Your Last Name *
3. Address
4. City
5. State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
6. ZIP Code
7. Email *
8. Home Phone
   xxx-xxx-xxxx
9. Work Phone
   xxx-xxx-xxxx
10. Mobile Phone
    xxx-xxx-xxxx
11. Please relate in 450 words or less the story of how your nominee demonstrated extraordinary leadership and Scouting virtues in ways that made a meaningful difference in the lives of others: *
12. 
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