NAME:  ____________________________________________________________

AGE (MUST BE AT LEAST 60):  __________

ADDRESS:  __________________________________________________________________________

CITY:  ____________________________  ZIP CODE:  _______________

PHONE: (DAY):  ____________________________   (NIGHT):  ________________________________

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?
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(2) HOW HAS THIS PERSON ATTEMPTED TO BETTER THE COMMUNITY?
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NOMINATED BY:  _______________________________________________________________________

ADDRESS:  _____________________________________________________________________________

CITY/STATE/ZIP CODE:  __________________________________________________

PHONE:  (DAY) ___________________________ (NIGHT) _________________________

DATE:  ___________________  SIGNATURE:  ________________________________________________

RETURN THIS NOMINATION FORM TO:

Judge Herman Marable, Jr.
68th District Court -Courtroom 1
McCree Courts and Human Services Building
630 South Saginaw Street
Flint, Michigan 48502
PHONE: (810) 597-7795