This award is for those who serve as managers or supervisors or who demonstrate leadership in another role.

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* 1. Nominee’s Name:

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* 2. Agency/Organization:

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* 3. Email Address:

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* 4. Phone Number:

Please provide the following information about you:

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* 5. Nominator’s Name:

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* 6. Agency/Organization:

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* 7. Email Address:

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* 8. Phone Number:

Please provide the contact information for two people who would act as references for the person you are nominating – people who would support the nomination.

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* 9. First Reference's Name:

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* 10. Email Address:

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* 11. Phone Number:

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* 12. Organization:

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* 13. Second Reference's Name:

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* 14. Email Address:

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* 15. Phone Number:

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* 16. Organization:

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