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Good Samaritan of the Year Award

Please explain in detail your reason for nominating the individual below. Refer to the criteria listed in the Call for Nominations and indicate how they apply to this candidate. Please keep your nomination STRICTLY CONFIDENTIAL.

* Indicates required information
Nominee's Name * 
Address: * 
Phone: * 
Reason for Nomination * 
Your Name: * 
Address: * 
Phone: * 
Email: * 

Note: If you would like to scan and email your nomination with any supporting materials, please email to If you have any questions, please feel free to contact us.



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