ACT, Inc.
College and Career Readiness Campaign
Workplace Success Award Nomination Form
Person Making Nomination___________________________________________________________
Title________________________________ LEA__________________________________________
Address_____________________________________ City/State/Zip Code_____________________
Telephone___________________________________ Email________________________________
All employer exemplars will be evaluated based on the following criteria (where applicable): (1) strong
partnerships with local community colleges; and (2) use of the NCRC (National Career Readiness
Certificate) in the hiring process. While ACT will validate each of these criteria to the extent possible, this
form will also provide the National Selection Committee with information about your employer’s
background and an evaluation of the unique qualities that make your employer exemplary.
If your employer is selected for the national Workplace Success Award, ACT will cover travel expenses to
Washington, DC, for one employer representative (and a spouse or partner) to be recognized at our
2013 National Gala on College and Career Readiness to be held on Tuesday, May 21, 2013.
EMPLOYER INFORMATION
BUSINESS NAME
MAILING ADDRESS
CITY / STATE / ZIP
ACT CODE
REPRESENTATIVE’S NAME
(First and Last Name)
REPRESENTATIVE’S TITLE
REPRESENTATIVE’S PHONE
NO.
USES NCRC?
(123-456-7890)
(Yes or No)
NUMBER OF EMPLOYEES
NUMBER OF NCRCCREDENTIALED EMPLOYEES
This form must be completed and submitted by Friday, March 15, 2013. Please direct any
questions to Sid Baker at 919-807-3478 or sid.baker@dpi.nc.gov. Thank you.
BUSINESS DESCRIPTION
Please use the blank space provided below to provide a description of the business (i.e., its purpose,
services offered, customers, etc.). (250 words maximum)
SPECIAL RECOGNITIONS
Please use the blank space provided below to detail the employer’s awards (area, state, or national),
memberships, partnerships (local service organizations, schools, etc.), and other notable achievements.
(250 words maximum)
EMPLOYER EVALUATION
Please use the blank space provided below to describe what makes this employer unique, citing specific
examples to support your claims. Consider the following questions: Does this employer clearly
communicate its skill needs to local colleges and high schools? Does the employer make an effort to
create and maintain diversity in its workforce? Do employees have opportunities to gain the new
knowledge and skills necessary for career advancement? How do the employer and its employees give
back to the community? (500 words maximum)
This form must be completed and submitted by Friday, March 15, 2013. Please direct any
questions to Sid Baker at 919-807-3478 or sid.baker@dpi.nc.gov. Thank you.