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Home > Activities > Annual Symposium > Nomination
2009 Symposium Nominations
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Nomination Form
* Required
I am making the following nomination-
Please check one:
Volunteer Award
The President's Award
Rural Health Clinician Award
The Leadership Award

Please make multiple submissions of this form to make more than one nomination.
Name of person being nominated OR Program being nominated (list information for contact person):

Nominee's Contact Information
Nominee's Full Name *
Agency: *
Mailing Address *
City *
State *
Zip *
Phone *
Fax
Please describe your reason for nominating this person or program. Other documentation (such as news clippings) or evidence of the nominee’s excellence will be accepted, but are not mandatory.
Individual making nomination:
Full Name
Phone
Fax
Email
May we tell the nominee your name when we notify him/her of the nomination Yes
No
Mail or fax completed forms and supporting materials to:
NERHRT
10 Benning St. Box 184
W. Lebanon, NH 03784
Phone: 603-643-2800, Fax: 603-643-2800
Nominations must be submitted on or before July 31, 2009
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10 Benning Street, Box 184, West Lebanon, NH 03784, 603-643-2800
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