Signature and Date

The above information and information contained in this entry is, to the best of my knowledge, true and correct. I understand that $500 of the award will be made directly to the school for use under my direction only. I also understand that $500 of the award will be made directly to me and I am responsible for taxes due as a result of this award. If I am a winner I hereby give my consent to use my name and photograph for publicity purposes only.

Applicant Signature:_________________________________________________ Date:____________

The above information and information contained in this entry is, to the best of my knowledge, true and correct and represents the teacher’s current assignment. I understand that $500 of the award will be made to the above named school for use only under the direction of the teacher. I also understand that $500 of the award will be made directly to the above named teacher and that neither I nor the school is responsible for taxes as a result of this award. Release time will be given to the above named teacher to attend the award ceremony if selected.

Administrator Signature:_______________________________________________________________

Position:_________________________________________________________ Date:_____________

Submit signed and completed
form in hard copy to:

Barry Wawak, GCAGS Awards & Nominations Chairperson
Core Laboratories, 8214 Polished Stone Circle, Houston, TX 77095

E-mail barry.wawak@corelab.com