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NOMINATION FORM
“RODRIGO ALVERNAZ Fraternal Award of Merit”
NOMINATION FORM
I. NOMINEE’S PERSONAL DATA
Name
*
First
Middle
Last
Street Adress
*
Apartment Unit
*
City
*
State
ZIP Code
*
Phone
*
Email
*
Date of birth
*
Date Format: DD slash MM slash YYYY
Occupation
*
Employer
Education
2. Luso-American Financial membership information
Number of years as member of Luso-American
*
Branch
*
LUSO
SPRSI
Local Council Name/number
*
City and State of Council
*
Positions Held
*
Local officer submitting nomination
Position
Street Adress
*
City
*
State
*
ZIP Code
*
Phone
*
Email
*
3. STATEMENTS
Please review the following three categories and provide your responses in the space provided.
A. FRATERNAL SUPPORT
*
B. COMMUNITY SERVICE
*
C. ACHIEVEMENTS, ACCOMPLISHMENTS & AWARDS
*
E. ADDITIONAL INFORMATION
*
Council Officer’s Printed Name
*
Position
*
Council Officer’s Signature
*
Upload Signed Document
Date
*
Date Format: DD slash MM slash YYYY
Attachment of any supporting documentation
*
Attachment of any supporting documentation
Consent
*
I agree to the Terms of Service & Privacy Policy
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