Please print this, complete it,

and return to your region rep

or

Copy it and email it to your region rep

MFBSA

Nomination Form

For

Region Agency of the Year Award

Agency: Program:

Address:

Phone/Fax: Email/Web Site:

What does this agency do, who do they serve? How long has the agency been in business?

Reason for Nomination: (Goal Reached, Special Skill, Notoriety in agency, Successes, Specialty, etc.

MFBSA Involvement:

Your Name:

Agency:

Phone:

Email: