Nomination Form

Company:
Business Address:
First Name:
Last Name:

Please be sure this person is in charge of completing the company's application.

Telephone:
FAX:
E-Mail:
Category (by Number of Employees):  Large (250+) Medium (100-250) Small (<100) Not-for-Profit

Note: Financial service companies are not eligible to participate.

Brief Description of Business:
Brief Explanation for Nomination:
Your Affiliation with the Nominee:  Employee Customer Vendor Shareholder Other

First Name:
Last Name:
Title:
Address:
Telephone:
FAX:
E-Mail:
Society Member:  Yes No