Nominee's Name *

First Name

Last Name

Nominee's Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Nominating Branch Member *

First Name

Last Name

Phone

(###)

###

####

Will the nominee attend the Award's Presentation? *

(Each branch is encouraged to cover some travel/accommodation expenses to assist nominees in attending the Presentation.)

Yes

No

Not sure yet

Waiver *

By submitting this nomination, I confirm that the I have obtained permission from the nominee for ORMTA to publish the names and photos included in this submission. The text or image(s) submitted may appear in electronic form on the Internet or in publications outside the control of ORMTA and ORMTA shall not be held responsible for any consequences that may arise from such unauthorized reproduction.

I agree