Nomination Form

Note: Businesses cannot nominate themselves, but can apply directly for a Unique Abilities Partner designation by submitting the Unique Abilities Partner Program Application Form. An asterisk (*) denotes required information.

Business Information:
* Name of the Business:

Physical Address of the Business:
* Address:
* City:

* State:

* Postal Code:

Contact Person at the Nominated Business:
* First Name:
* Last Name:
Title:
* Phone Number:
* Email Address:

Additional Information
Is there anything you’d like to share with us about this great business/organization?

Contact Information for Person Submitting the Nomination:
First Name:
Last Name:
Relation to Business:
Phone Number:
Email Address:

Please select all Eligibility Criteria that you believe apply to the Nominated Business: (*Selection of at least one criterion is required)

A. Employment of at least one individual with a disability. Such employees must be residents of Florida and must have been employed by the business for at least nine months before the business applies for a Unique Abilities Partner designation.

B. Contributed to local and/or national disability organizations or made contributions in support of individuals who have a disability. Such contributions may be financial or in-kind, including employee volunteer hours. A business with 100 or fewer employees must make a financial or in-kind contribution of at least $1,000 and a business with more than 100 employees must make a financial or in-kind contribution of at least $5,000.

C. Established or contributed to the establishment of a program that contributes to the independence of individuals who have a disability. A business with 100 or fewer employees must make a financial or in-kind contribution of at least $1,000 in the program and a business with more than 100 employees must make a financial or in-kind contribution of at least $5,000.

If you are completing a hard copy nomination, please mail the nomination form to:

Unique Abilities Partner Program
The Agency for Persons with Disabilities
4030 Esplanade Way, Suite 380
Tallahassee, FL 32311