Please print this form, complete it,

and send it to MFBSA by email or postal mail

MFBSA

Nomination Form

For

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: