Sam Miller Application Applicant's Contact Information First Name (required) Last Name (required) Street Address (required) Apt/Box Number City (required) State (required)—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of Columbia, WashingtonFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zipcode (required) Phone Number (required) Email (required) How did you hear about the Sam Miller Award? Disability Advocacy Describe your involvement with the disability community and the Bender Lead On Team. What have you done to take a stance against bullying? (required) Lead On! Describe what you believe makes you a good leader. (required) Volunteer Experience Summarize your volunteer experience. (required) Education/Achievements List your education (completed or in progress) and your achievements. (required) Mentor's Contact Information First Name (required) Last Name (required) Street Address (required) Apt/Box Number City (required) State (required)—Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of Columbia, WashingtonFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zipcode (required) Phone Number (cell/home) (required) Phone Number (work) (required) Email (required) Letter of Nomination Submit the letter of nomination from the mentor listed above, with your application. This letter must be signed by the mentor, in order to be considered for application. Agreement and Signature By submitting this application, I affirm that the facts set forth are true and complete. I understand that any false statements, omissions, or other misrepresentations will result in my disqualification. Upload letter (required) Allowed file types: pdf,doc,docx,txt,jpg,tiff Signature (type your full name) (required) Date (required)