Norman W. Duzen Community Service Award Nomination Form

Nominator's Information
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Nominator's First Name

Nominator's Last Name

Nominator's Mailing Street

Nominator's Mailing City

Nominator's Mailing State

Nominator's Mailing Zip

Nominator's Email Address

Nominator's Phone Number

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Nominee Information
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Nominee First Name

Nominee Last Name

Nominee Mailing Street

Nominee Mailing City

Nominee Mailing State

Nominee Zip

Nominee's Email Address

Nominee's Phone Number

Volunteer Role 1 Information

Volunteer Role 1

Number of Years - Volunteer Role 1

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Number of Hours Per Week - Volunteer Role 1

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Leadership Position - Volunteer Role 1

Specific Examples of Volunteer Efforts - Volunteer Role 1

Impacts of individual, organization or community - Volunteer Role 1

Volunteer Role 2 Information

Volunteer Role 2

Number of Years - Volunteer Role 2

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Number of Hours Per Week - Volunteer Role 2

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Leadership Position - Volunteer Role 2

Specific Examples of Volunteer Efforts - Volunteer Role 2

Impacts of individual, organization or community - Volunteer Role 2

Volunteer Role 3 Information

Volunteer Role 3

Number of Years - Volunteer Role 3

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Number of Hours Per Week - Volunteer Role 3

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Leadership Position - Volunteer Role 3

Specific Examples of Volunteer Efforts - Volunteer Role 3

Impacts of individual, organization or community - Volunteer Role 3

Other Information

Other awards or honors that the nominee has received

Additional comments

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