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NPIN Featured Partner Nomination Form

Nominees should be community-based, local government, or non-profit HIV/AIDS, viral hepatitis, STD, or TB prevention organizations in existence for at least three years.

Fields marked with * are required.


Person Making the Nomination
*Name:
Street Address:
City:		State:	ZIP Code:
*Phone:	(xxx-xxx-xxxx)
*E-mail:
*Affiliation or relationship with nominated organization (you may nominate your own organization):

Nominated Organization
Please check if Nominated Organization contact information is same as the person making the nomination.
* Name:
*Street Address:
*City:		*State:	*ZIP Code:
*Phone:	(xxx-xxx-xxxx)
Year Founded:
Web Site:
Is the organization a CDC grantee? (nominee does not have to be a CDC grantee):
If yes, please provide:
	CDC Project Officer Name:
	E-mail:
	Phone:	(xxx-xxx-xxxx)
Please provide the names of the organization's top three funders:

Follow-up Contact at the Organization:
Please check if follow-up contact is same as the person making the nomination.
*Name:
Street Address:
City:
State:
ZIP Code:
*Phone:
*E-mail:

For use on the NPIN Web site, please provide below an overview of the organization and information on a particular program. Please include information that would be useful to others working in the field, such as background information on programs and services, populations served, and online resources and publications. If the organization implements any CDC recommended programs, please describe one in the “Program to Highlight” section. If not, please describe a successful program of the organization and its impact on the stakeholders. Thank you!


*Background on Nominated Organization: (Maximum of 1000 words.)

*Program to Highlight on NPIN Web Site: (Maximum of 1000 words.)

NPIN Featured Partner Nomination Form

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