Nominee
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Address
City
Postal Code
Phone
Is the Nominee aware of this nomination?
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Yes
No
SELECTION CRITERIA:
A. Description of Contribution/Achievement:
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Type examples
B. Explanation of impact (please elaborate and/or give examples):
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C. Level of contribution (i.e., local, regional, provincial, or national):
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Nominated by:
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Agency
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Position/title
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Business phone number:
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E-mail address:
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Security Code
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