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Hall of Fame Nomination Form 2022
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First Name
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Last Name
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Phone
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Address
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City
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State/Province
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Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Ontario
Prince Edward Island
Quebec
Saskatchewan
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Postal Code
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E-mail
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Age(s)
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Select Male or Female
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Select Male or Female
Male
Female
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Nominated by
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Nominated by
A Group
An Individual
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Nominator's Name (group or individual)
Primary Contact if Group
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Address
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City
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Zipcode
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Phone
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E-mail
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How is the nominee actively involved in the community since reaching the age of 60? How does the nominee inspire you?
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Please list and describe nominee's volunteer efforts (unpaid, not a job). Please include the length of time of the nominee's involvement with each volunteer activity.
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How has the nominee improved the quality of life of others?
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Please list and describe any of the nominee's awards/honors and special achievements.
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If the nominee serves or has served in leadership roles within organizations, please describe them.
Please include any additional information about the nominee's life
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