1. Biographical Data of Candidate

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* 1. What is your Nominees first and last name? (Include Maiden name) 

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* 2. What is your Nominees full street address?

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* 3. What is your Nominees phone number?

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* 4. What is your Nominees email address?

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* 5. Category of the Nominee. Please select only one nomination category.

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33% of survey complete.

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