Please select the award for which you are nominating:

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* 1. Please select the award for which you are nominating:

Name and address of nominee or program: (If program, identify director)

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* 2. Name and address of nominee or program: (If program, identify director)

A brief description of nominee's achievements, contributions, and/or service to rural care: 

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* 3. A brief description of nominee's achievements, contributions, and/or service to rural care: 

Personal and/or professional association with the nominee: (First-hand knowledge of achievements)

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* 4. Personal and/or professional association with the nominee: (First-hand knowledge of achievements)

Additional information which should be considered by the awards committee: 

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* 5. Additional information which should be considered by the awards committee: 

Nominator name and contact information: 

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* 6. Nominator name and contact information: 

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