Nomin Form

ALABAMA RURAL HEALTH ASSOCIATION

RECOGNITION PROGRAM AWARDS NOMINATION

1. As a member of the ARHA, I would like to make a nomination for the:

(Check One)

___ Rural Health Provider Exceptional Achievement Award

___ Rural Volunteer Excellence in Service Award

___ Billie Gilliland Exceptional Contribution to Rural Accident Prevention Award

2. The individual, group, or organization I am nominating is:

___________________________________________________________________________________________________

3. His/her address/phone/fax/email is:

___________________________________________________________________________________________________

_____________________________________________________________________________

4. This person is deserving of this award because: (Attach additional sheets as needed.)

_________________________________________________________________________

4. My name/address/phone/fax/email is:

_________________________________________________________________________

Mail Nomination Form To:

Alabama Rural Health Association

P. O. Box 4509

Montgomery, AL 36103

Or Send by Facsimile To:

(334)206-5434

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