| Chapter making nomination: * |
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| Nominee (First Middle Initial Last): * |
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| Position/Title: * |
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| Place of Business: * |
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| Business Address: * |
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| Business City, Zip Code: * |
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| Number of years active with this chapter/program: * |
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| Please list the contributions of this individual as well as rationale for this nomination. (Minimum of 5) |
| Reason 1: * |
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| Reason 2: * |
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| Reason 3: * |
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| Reason 4: * |
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| Reason 5: * |
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| Reason 6: |
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| Reason 7: |
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| Reason 8: |
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| Reason 9: |
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| Reason 10: |
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