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* 1. Please provide your contact information:

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* 2. Are you nominating yourself or someone else?

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* 3. If your submission is not for yourself, have you notified the nominee about this nomination?

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* 4. Please provide contact information for your nominee (if different from your contact information):

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* 5. What position(s) are you nominating for? 
Select as many as apply.

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* 6. Please provide a statement (no more than 500 words) that communicates:
-The nominee's commitment to be an active and engaged member of the Brain Injury Advisory Committee
-Why you believe the nominee should be selected to be part of the Committee

The Committee is accepting nominations through 5pm, Friday, April 26, 2019. Questions? Please contact Monica Lichi
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