Q5K Small Business Nomination Form
Name of Nominator
Your name
First / Last *
Phone *
Email *
Small Business Nominated
Who are you nominating?
Business Name *
Estimate Number of Employees at Business. *
Business Owner: First Name / Last Name *
Business Website *
Business Phone *
Business Nominee Email *
Business Nominee Address
Street Address *
Street Address Line 2
City *
State *
Zip Code *
Story/About
Use this space to tell us why you feel this small business should receive one of the donations.
*
By submitting this nomination; I hereby certify that the responses and information provided in this nomination form are true and accurate to the best of my knowledge. I understand any omission or misstatement can result in the forfeiture of this gift. *
Submit
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