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1.
Nominator
First Name
M.I.
Last Name
Email Address
Daytime Phone
Evening Phone
2.
Address of Nominator
Street Line 1
*
Street Line 2
City
*
Alaska
Alabama
Arizona
Arkansas
California
Colorado
Connecticut
D.C.
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
*
Zip Code
*
3.
Nominator Date of Birth
Month
*
Day
*
Year
*
January
February
March
April
May
June
July
August
September
October
November
December
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
4.
What kind of help is needed? (i.e. Help with a garden, read to a child, play board games with seniors, tutor a child, walk a neighbor's dog, take inner city kids to a ball game, help a senior citizen clean up their home, have a conversation with a retired veteran, etc. - 160 Characters Maximum) - Disclaimer: Monetary help is not available for those you nominate; this is a volunteer work-based opportunity to bring our community together. If you would like to donate money through Give 7 go to https://volunteer.united-e-way.org/cwosdc-2/donate/
*
5.
Describe why this person(s) should be considered for assistance (2,000 Character Maximum) - Disclaimer: Monetary help is not available for those you nominate; this is a volunteer work-based opportunity to bring our community together. If you would like to donate money through Give 7, https://volunteer.united-e-way.org/cwosdc-2/donate/
*
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