Mac McClure Nomination Form

Nomination Form

Nominations are due on or before October 19, 2018.

NOMINATED ORGANIZATION INFORMATION

Organization Name:

Organization Address:

Street Address City State / Province / Region Postal / Zip Code

Organization Contact:

First

Last

Phone: (Cell or Home)

Area Code

Phone Number

Phone: (Work)

Area Code

Phone Number

Fax:

Area Code

Phone Number

E-mail:

SUMBITTED BY

Name:

First

Last

Title:

Business Name/Organization (as applicable):

Address:

Street Address City State / Province / Region Postal / Zip Code

Phone: (Cell or Home)

Area Code

Phone Number

Phone: (Work)

Area Code

Phone Number

Fax:

Area Code

Phone Number

E-mail:

APPLICATION QUESTIONS

1) Please provide specific examples of how your nominated organization, motivates and serves as an advocate for the promotion of the UBS community blood program.

2) How does your nominated organization play an active role in the success of the UBS/AZ community blood program? Please provide specific examples that demonstrate how they support and encourage participation.

3) What are the nominated organization’s areas of greatest innovation and impact on the UBS/AZ community blood program? Please provide specific examples.