Nomination Form
If you know someone who works in the healthcare or wellness industries and they are making a positive impact in their organization, within their industry or around our community please nominate them today. We would like to recognize their hardwork! Nominations close October 28th, 2019.
Email address *
NONIMATOR'S INFORMATION
The NOMINATOR is you, the person filling out this form.
First Name *
Your answer
Last Name *
Your answer
Email address *
Your answer
Phone Number *
Your answer
Would you like to submit anonymously? *
NOMINEE'S INFORMATION
This section should be filled out about the person being nominated. Please include as much information about the person being nominated as possible. The information provided will be used to create the bio to honor this person. You or the nominee may be contacted for follow up information if needed.
First Name *
Your answer
Last Name *
Your answer
Email address *
Your answer
Phone Number *
Your answer
Why do you feel this person should be nominated? *
Your answer
What professional affiliations is this person a part of?
Your answer
What civic affiliations is this person a part of?
Your answer
Has this person received any special honors or Awards in their industry?
Your answer
Tell us a little about this person. Their personal philosophy, goals and influences/influences.
Your answer
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This form was created inside of Alaska Dispatch.