Nomination Form

    1.
    NOMINATOR INFORMATION

    Name *

    Company/Organization (if applicable)

    Relationship to Nominee *

    Telephone *

    Email *

    2.
    NOMINEE INFORMATION

    Name *

    City, County & State of Residence:

    City

    County

    State

    Telephone

    Email

    Maritime Company / Logistics Company / Maritime Affiliation (if known)

    Examples: Logistics company, terminal operator, tug & barge company, shipyard, port authority, offshore service company, or other maritime organization.

    3.
    REASON FOR NOMINATION

    Please provide a brief summary of the nominee's medical situation and why you believe assistance may be appropriate.

    4.
    IS THE NOMINEE AWARE OF THIS NOMINATION?

    5.
    CERTIFICATION

    I certify that the information provided is true and correct to the best of my knowledge.

    Signature *

    Date *

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