Emmy Statue

Gold and Silver Circle Nomination Form

Name of Nominee




Day Phone:

Evening Phone:

Employment Status:

If employed, list current place of employment:

The following items must be attached and completed in full or the application will be disqualified. PLEASE NOTE: only files with .doc .docx and .pdf extensions may be uploaded.

  1. Letter stating why candidate is deserving of induction into Gold/Silver Circle®. Please craft this letter so those who may not know the candidate get a sense of who this person is, along with two letters of recommendation.

  2. A comprehensive biography that outlines the nominee’s career path, work in the Mid-America area, involvement in organizations associated with the medium and key accomplishments. Employment history and dates must be included.

  3. First Letter of Recommendation:

  4. Second Letter of Recommendation:

Submitted By:

Contact Phone Number:

Email Address: