Nomination Form for the James H. Gilliam

Nomination Form for the James H. Gilliam, Jr. Award

PART A – MUST COMPLETE

Name of Nominee*

First NameLast Name

Title*

Address*

Street Address

Street Address Line 2

CityState

Zip Code

All nominations will be reviewed and researched by the James H. Gilliam, Jr. Award Committee. The James H. Gilliam, Jr. Award will be presented to the person who, in the belief of the committee, has made the most significant contribution to the health, welfare or benefit of the community.

Deadline for receiving nominations is September 6, 2017

For questions contact Denise Griffin at denise.griffin@heart.org or 302-286-5704.

PART B

PLEASE DESCRIBE THE ACHIEVEMENT(S) OF THIS NOMINEE:*

PLEASE FEEL FREE TO ADD ANY ADDITIONAL INFORMATION: TESTIMONIALS, LETTERS OF RECOMMENDATION OR REFERENCES WITH CONTACT INFORMATION.

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PART C

Name of person making nomination*

First NameLast Name

E-mail*

Phone Number*

Area CodePhone Number

Date of Nomination*

MonthDayYear