Department Economic Opportunity

Florida Unique Abilities Partner Program 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:
(*Email OR Phone Number is required)



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
Department of Economic Opportunity
107 East Madison Street
MSC G-229
Tallahassee, FL 32399


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