We (name of newspaper/group) do request and authorize that an individual plaque(s) be made in advance for presentation at the fall conference to any staff member who receives a first-place award. (Note: 1st place plaques are automatically awarded to winning newspapers - this form authorizes that individualized plaques be made for presentation to 1st place award-winning staff members). Plaques are $35 each. (Sorry, individual plaques will not be available for order after the awards ceremony.)

This request includes the following newspapers (attach an additional sheet, if necessary):

Name/title of person authorizing plaque(s)

Address, city, state, ZIP

Phone #

Signature of person authorizing plaque(s):