Nominate a Special Senior today and enter to win a FREE Medical Alert System for 6 Months!*

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* 1. What is your name?

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* 2. What is the name of the person you are nominating?

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* 3. What is your relation to the nominee?

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* 4. How old is the nominee?

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* 5. What is the nominee’s current living situation?

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* 6. Has this senior ever experienced a fall?

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* 7. How has this senior impacted you or his/her community?

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* 8. What is your favorite trait about your nominee?

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* 9. Is your nominee on a fixed income?

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* 10. What is your email address?

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* 11. What is the best number to reach you?

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