Leadership Nomination Form

Full Name of Person Submitting Nomination:

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Email

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First Name

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Last Name

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Email

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Address

Address Line 1

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Address Line 2

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City

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State

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Postal Code

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Country

Phone Number

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Specify President-Elect or Director Nomination:

President-Elect

Director

Please provide an explanation of why the nominee should be considered for an ACVP leadership position:

Please provide a brief summary of the nominee's past involvement with ACVP:

Nominee Information