Name of Nominee ______________________________________

School(s) ____________________________

Years of Service in Brookline _______

Position (s) ___________________________________________________

Name of Nominator(s) ___________________________________________

Signature(s) ________________________________

______________________________________________________

Please print and attach this form to the letter stating why you have selected this person for nomination. Thank you.

DEADLINE: Friday, March 24, 2006, c/o Personnel Office, 5th Floor, Town Hall