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* 1. First/Last Name:

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* 2. Primary Contact Number:

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* 3. Primary Email Address:

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* 4. Employer:

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* 5. Title/Occupation:

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* 6. T1D Connection:

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* 7. Brief summary of candidate’s Professional Successes, Community Involvement, Leadership, Fundraising and Non-Profit Experience: 

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* 8. Please share how the candidate will exemplify the Qualities of High Impact JDRF Boards as outlined below:

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* 9. Nominated By:

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* 10. Nominator's Contact Information:

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