****PLEASE RETURN BY Tuesday, March 5, 2013****(please TYPE or print clearly)

Nominee Name: ______________________________________________________________________________

Organization/Business: _________________________________________________________________________

Title: _____________________________________Office #: ___________________________________________

Cell Phone #: ______________________________ E-mail: ___________________________________________

Mailing Address: ______________________________________________________________________________

City: ____________________________________ Zip: __________ County: _____________________________

1. Nominee Category: (Choose a category that most likely fits the area of expertise of the individual being nominated.If your candidate is making an impact in another area please indicate it in the “Other” field). □ Arts □ Business □ Education □ Social Services □ Community Activism □ Other _________________________________________________________________________

2. Nominee’s Age Range: □ 20-29 □ 30-39 □ 40-49 □ 50-59 □ 60-69 □ Other _______

3. Nominee’s Ethnic Background:□ Asian Indian □ Bangladeshi □ Cambodian □ Chinese □ Filipino □ Hmong □ Indonesian □ Japanese □ Korean □ Laotian □ Malaysian □ Pakistani□ Native Hawaiian □ Sri Lankan □ Taiwanese □ Thai □ Vietnamese □ Other Asian Pacific American (please list) _____________________________________________

4. Separately, but not exceeding three pages typed, please discuss the following: a. Significant Contributions: (750 words maximum): Describe why your nominee deserves recognition as a KCET

Local Hero. Highlight the major contributions your nominee is making to his/her profession beyond the scope of his/her paid position and community, and how he/she inspires others.

b. Community Involvement/Volunteer Work: (300 words maximum): Discuss your nominee’s commitment to community service and any community involvement/volunteer work in which the nominee participates, including the number of years of involvement.

c. Awards/Recognition Received: (200 words maximum): List any awards the nominee has received. Of particular interest are awards received at the national level, if any.

Nominated by: _________________________________________________________ (please TYPE or print clearly)

Organization/Business: ________________________________________________________________________

Title: __________________________________________ Phone #: ____________________________________

Cell Phone #: __________________________________ E-mail: _______________________________________

Mailing Address: ______________________________________________________________________________

City: _______________________________________________ Zip: __________________ State: ____________

What is your relationship to the nominee?__________________________________________________________

Where did you hear about the Local Heroes Program?____________________________________________________Please send this form along with the necessary information (Item #4) as follows:

E-mail to kcetlocalheroes@kcet.org, fax to 747-201-5877 or mail to KCET Local Heroes, 2900 West Alameda Ave., Burbank, CA 91505.

To submit an online nomination visit kcet.org/heroes. Questions? Please contact KCETLink at 747-201-5288 or via e-mail at kcetlocalheroes@kcet.org

Photocopy this form as needed.

Asian Pacific American Heritage Month2013 Candidate Nomination Form