Proud of our past, Confident of our future.
Month and Year*
Name, Title, Organization, Location, and contact email address (Enter the personal identification information of the individual being nominated)*
Reason for nomination (Describe the nominee’s accomplishment or reason for acknowledgment.)*
Picture 1
Picture 2
Nominator First Name*
Nominator Last Name*
Nominator Email*
Nominator Phone
Nominator Address 1
Address 2
City
State
Zip
Country
Nominator Title
Nominator Company
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