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1. What is your information? (Required.)

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2. I am nominating: (Required.)

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3. Who would you like to nominate?

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4. How many members are in the nominees immediate family?

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5. Do you wish to remain anonymous if you or the family you nominated is selected? (Required.)

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6. Please explain the family or individual's circumstances (Required.)

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7. Why do you feel that you or this family in particular deserves to be selected? (Required.)

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