Nomination Form
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Please fill out the following...
Agency Name (if applicable):
Nominating Contact Person:
Phone Number:
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)
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Email Address:
Nominee's Name:
Nominee's Address:
Nominee's Income:
Nominee's Phone:
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)
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Nominee's Situation (housing, family, disabilities, etc.):
Nominee's Special Need:
What would fill that Need?:
Estimate of Cost to fill Nominee's Need (please contact vendors for cost of items to be purchased including bids when professional services are required):
Please check if the nominee would be willing to have their story in the Quad City Times: