First Name*:
Last Name*:
Email (if known):
Phone # (if known):
Philanthropic Activity #1*:
Length of time*:
Why it stands out*:
Philanthropic Activity #2:
Length of time:
Why it stands out:
Philanthropic Activity #3:
Length of time:
Why it stands out:
Philanthropic Activity #4:
Length of time:
Why it stands out:
Philanthropic Activity #5:
Length of time:
Why it stands out:
Additional info/comments:
Your relationship to Nominee*:	Family Friend Co-worker Business Associate No relationship, just know of philanthropy

Your Information:

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Last Name*:
Email*:
Phone #*:
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