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| Department (If Applicable): |
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| Title/Position (Optional): |
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| Work Telephone Number (Optional): |
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| Nominator's Name: |
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| Department (If Applicable): |
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| Title/Position (Optional): |
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| Nominator's Phone: |
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| Nominator's E-mail Address: |
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| Is it okay if we publish your name and nomination? |
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Yes No |
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| Describe the Act of Kindness that prompted this nomination. |
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