Presented by Astellas

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* 1. Nominee's Contact Information

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* 2. Your contact info, if nominating someone else

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* 3. Nominee's information continued...

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* 4. Tell us about yourself and your transplant journey. OR tell us about the person you are nominating and his/her transplant journey.

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* 5. The Bounce Back, Give Back Award aims to “Recognize organ transplant recipients who achieve a great quality of life.” How do you or your nominee exhibit this?

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* 6. Achievements worthy of recognition can range from significant achievements in a career (academic, nonprofit work, athletics, entertainment, politics) to simply leading a fulfilling life with family and loved ones. Please list any achievements that the Bounce Back, Give Back Award committee should be aware of.

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* 7. To the best of my knowledge, everything included in this form is accurate. Please initial.

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* 8. To the best of my knowledge, I or the person I am nominating will be able to go to Aspen in December if selected as a winner. Please initial.

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* 9. I agree to the Contest Rules. Please initial.

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