JUDGE HERMAN
MARABLE  
67th DISTRICT COURT
FIFTH [FLINT] DIVISION
630 S. Saginaw St.  Flint, Michigan  48502

NAME:  ____________________________________________________________________________________________________________________________

ADDRESS: __________________________________________________________________________________________________________________

CITY:  ____________________________  ZIP CODE:  _______________

PHONE: (DAY):  ____________________________   (NIGHT):  ________________________________  (CELL #): ______________________________

EMAIL: ____________________________________


ORGANIZATIONS/MEMBERSHIPS:

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COMMUNITY ACTIVITIES/ACCOMPLISHMENTS: 

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(1) WHY SHOULD THIS PERSON BE SELECTED AS SENIOR CITIZEN OF THE MONTH?       [Attach more sheets if needed]

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(2) HOW HAS THIS PERSON ATTEMPTED TO BETTER THE COMMUNITY?       [Attach more sheets if needed]

 

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NOMINATED BY:  ___________________________________________________________________________________________________________

ADDRESS:  _________________________________________________________________________________________________________________

CITY/STATE/ZIP CODE:  __________________________________________________

PHONE:  (DAY) ___________________________ (NIGHT) _________________________  (CELL #): ________________________________________

EMAIL:  _________________________________

DATE:  ___________________  SIGNATURE:  ________________________________________________