THE MILLENNIUM AWARD

Nominee Name (required)

Nominee Title (required)

Nominee Organization (required)

Please give a brief description of the nominee, their work and why you think they should receive the Award. (required)

Nominee Professional or Community Group Membership(s) (required)

Nominee Previous Honors

List web links or social media of the nominee to further support your nomination. (required)

Please provide contact information for the nominee so that we may be able to reach them should we decide to award them.

Nominee Address (required)

Nominee City (required)

Nominee State (required)

Nominee Zip Code (required)

Nominee Email Address (required)

Nominee Phone (required)

Your Name (required)

Your Email (required)

Your Phone (required)

May we inform the nominee that you nominated them? (required)

May we contact you if we have questions? (required)

Thank you for your nomination!

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