Admiralships

Date of Request: _________________________________________________________

Person Requesting: _________________________________________________________

Address: _________________________________________________________

_________________________________________________________

Phone: _________________________________________________________

Name of Admiral: _________________________________________________________

Address: _________________________________________________________

_________________________________________________________

Date of Admiralship*: _________________________________________________________

Please mark appropriate box: □ Pick Up □ Mail to Nominee □ Mail to Nominator

Date Due: _________________________________________________________

Reason for Nomination (Please include contribution to the citizenry of Nebraska): ___________________________________________________________________________

___________________________________________________________________________

*Received date will be used if no date is provided.

Please return to Noelle Rupiper, Office of the Governor, State Capitol, P.O. Box 94848, Lincoln, Nebraska 68509 with appropriate notice of two to three weeks.

For Governor’s Office Only

Approved: _____________________

Governor’s Signature: ____________

Complete: ______________________