NOMINATION FORM

NOTE:
The information collection survey you are currently on is for nominating an individual to the Blue Stars Hall of Fame, Class of 2018.

If you are instead attempting to provide a letter of support for an individual someone else has nominated, please go to the Blue Stars 2018 Hall of Fame - Support Letter Form.

This data collection survey is 3 pages long. Please complete the entire survey before pressing the "Submit" button on page 3. If you exit the survey or close your browser before pressing the "Submit" button, you will not be able to go back and edit your input.

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This year, up to three (3) new inductees will join the esteemed members of the Hall of Fame. Nomination submissions are due by March 12, 2018. To nominate a candidate for the Blue Stars Hall of Fame, complete this online information collection survey. Each individual may submit and nominate only ONE candidate per year.

Following is the outline for the required information to be provided:

NOMINATED CANDIDATE'S INFORMATION: complete name, address, personal/work telephone numbers, and email. If the candidate is deceased, include contact information for a close relative (if possible).

YOUR INFORMATION: complete name, address, personal/work phone numbers, email, and documentation of why you believe this nominated candidate should be considered for membership in the Blue Stars Hall of Fame. This input needs to identify how the candidate nominee has made significant contributions to the success of the Blue Stars and its members.

Brian Whitty
4615 Camden Rd.
Madison, WI 53716
Phone: 608.225.4931
brian.whitty@bluestars.org

REMINDER: If you are attempting to provide a letter of support for an individual that someone else has nominated, do not complete this form, but instead go to the Blue Stars 2018 Hall of Fame - Support Letter Form.

* 1. What is the NOMINEE'S name (first name last name)?

* 2. Is the NOMINEE deceased?

* 3. What is the NOMINEE'S address (Street/PO Box, City, State, ZIP)?
If the NOMINEE is deceased, provide address of a close relative contact (if possible).

* 4. What is the NOMINEE'S Home or Mobile phone number (please include area code) ?
If the NOMINEE is deceased, provide phone number of a close relative contact (if possible).

* 5. What is the NOMINEE'S Work phone number (please include area code) ?
If the NOMINEE is deceased, provide work phone number of a close relative (if possible).

* 6. What is the NOMINEE'S email address ?
If the NOMINEE is deceased, please provide email of a close relative contact (if possible).

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