Twenty-Five Year

LOUISIANA CONFERENCE ON WATER SUPPLY, SEWERAGE, AND INDUSTRIAL WASTES, INC.

TWENTY FIVE (25) YEAR AWARD

NOMINATION FORM

The Award will be presented in recognition of twenty-five years of membership in the Louisiana Conference o Water Supply, Sewerage, and Industrial Wastes, Inc.

The purpose of honoring Conference Members with this award is to recognize faithful support of and contributions to the Conference and the water/wastewater field over a 25 year period and to encourage others to similar continuous interest and service to the Conference and the industry.

Date:

____________________

1. Nomination submitted by:

_________________________________________________________________________

2. Name of Nominee:

_________________________________________________________________________

3. Address:

_________________________________________________________________________

4. Present Employer:

_________________________________________________________________________

5. Title of Present Position:

_________________________________________________________________________

6. Certification Status: Louisiana Classification:

_________________________________________________________________________

Field:

_________________________________________________________________________

7. Summary of positions, assignments, employers over the 25 year period of membership in the Conference:

_________________________________________________________________________

8. Other Honors received:

_________________________________________________________________________

9. Comments:

_________________________________________________________________________