TWIN

Please complete the nomination form by February 15, 2007.  If you have any questions or concerns, contact Rebecca Taguma, 343-3688 ext. 11.

Nominee Information

Name:

FirstMiddleLast

Title:

(EXACTLY AS YOU WOULD LIKE IT TO APPEAR ON ALL PUBLICATIONS)

Company Name:

(EXACTLY AS YOU WOULD LIKE IT TO APPEAR ON ALL PUBLICATIONS)

Business Address:

City     Zip Code

Business Phone: 

Preferred e-mail address:

Home Address:

City     Zip Code

Home Phone:

Total length of time with company:(Note:  Not eligible if less than TWO years)

College/University:  

(If applicable)

SchoolDegreeDate

SchoolDegreeDate

Special or Advanced Training:

(If applicable)

Sponsoring Company Information

CEO or Company President:

(EXACTLY AS YOU WOULD LIKE IT TO APPEAR ON ALL PUBLICATIONS)

Actual Title of CEO

or Company President:

(EXACTLY AS YOU WOULD LIKE IT TO APPEAR ON ALL PUBLICATIONS)

Mailing Address

for CEO

Company President:

City     Zip Code

Company representative providing information:

First NameLast Name

Title:

Phone:

Email address:

Selected Contribution category and amount (see donor participation form for more information):

If you selected 'Other', please explain:

24-hour Domestic Violence Hotline: (208) 343-7025         24-hour Rape Crisis Hotline: (208) 345-7273 

DISTINGUISHED GRAND PARTNER ($20,000 and above)
DISTINGUISHED PARTNER ($15,000 and above)
DISTINGUISHED GRAND BENEFACTOR ($10,000 and above)
GRAND BENEFACTOR ($5,000 and above)
BENEFACTOR ($4,000 and above)
CONTRIBUTOR ($2,000 and above)
SUPPORTER ($1,000 and above)
OTHER (please explain below)