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* 1. Name of nominated worksite

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* 2. Address of nominated worksite

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* 3. Website of nominated worksite

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* 4. Name of individual completing nomination form

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* 5. Phone number of individual completing nomination form

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* 6. Email address of individual completing nomination form

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* 7. Please explain why you are nominating this worksite to receive the TCHD Breastfeeding Friendly Worksite Award. How does the nominated worksite provide  breastfeeding support? Please give specific examples.

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* 8. If able, please provide a contact person's name and contact information (phone number or email address) at the nominated worksite.

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