Your Name

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* 1. Your Name

Your Business

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* 2. Your Business

Your Work Phone:

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* 3. Your Work Phone:

Your E-Mail

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* 4. Your E-Mail

Name of Nominee

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* 5. Name of Nominee

Nominee Title

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* 6. Nominee Title

Nominee Business

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* 7. Nominee Business

Business Address

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* 8. Business Address

Work Phone

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* 9. Work Phone

E-Mail

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* 10. E-Mail

Select an Award 

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* 11. Select an Award 

Names of any other businesses or number of franchises:

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* 12. Names of any other businesses or number of franchises:

Year main business began:

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* 13. Year main business began:

Total number of employees:

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* 14. Total number of employees:

Please write any additional comments you may have about your nomination.

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* 15. Please write any additional comments you may have about your nomination.

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