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    *Your Name

    *Company Name

    *Address Line 1

    Address Line 2

    *City

    *State / Prov    

    *ZIP / Postal Code    

    *Contact Phone

    *Contact Email Address

    *This is to second the nomination of:

    *for the award of:

    *How long has this person been in the industry (estimate if unknown)

    *How long have you known this person?

    *Please describe why the person or store indicated is deserving of the award.

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