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* 1. Nominee's Full Name:

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* 2. Nominee's Address

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* 3. Nominee's Birthdate

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* 5. Award Being Nominated For (Please choose one)

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* 6. What are the nominee's unique and outstanding achievements? For example: outstanding performance in course work; overcoming barriers; making a distinct difference etc.

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* 7. How has the nominee contributed to the well-being of community members? For example: contributions which enhance the lives of others; being an agent for change either within the family, peers or the community; volunteer work and/or employment etc.

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* 8. How has the nominee contributed as a role model for others? For example: enriched or enabled others by virtue of involvement with or influence; demonstrated vision and pioneering spirit; educate, support and encourage others; good interpersonal relationships etc.

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* 9. Name of 1st person who is doing the nominating?

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* 10. Email of 1st person who is doing the nominating:

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* 11. Phone Number of the 1st Person who is doing the nominating?

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* 12. Name of 2nd Person who is doing the nominating

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* 13. Email of 2nd Person who is doing the nominating:

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* 14. Phone Number of 2nd Person who is doing the nominating?

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