Nomination Form

About | Nomination Criteria | Online Nomination Form | Printable Nomination Form

* Indicates a Required Answer

Name *

Title First Last Suffix

Contact Phone Number *

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### ### ####

Alternate Phone Number

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### ### ####

Email (preferred, but not required)

Address

Street Address
Address Line 2
City State Zip

* Indicates a Required Answer

Name of Company *

Company being nominated Program Name

Number of employees (if known)

Phone Number (if known)

- -
### ### ####

Other Phone (if known)

- -
### ### ####

Address (if known)

Street Address
Address Line 2
City State Zip

In three hundred words or less please explain why you feel this business is worthy of recognition from the Washington State Secretary of State’s Office. Please include all contributions, accomplishments, impacts and/or anything else that might showcase the business. If attached, please write “See Attached” in the space provided below.

Why? *

Additional Comments
Is there anything else of which the Secretary of State should be aware?

Do you have photos you would like to add?

Photos uploaded:

# of photos uploaded:

The nomination must have at least one reference who will be contacted to verify the contribution of the nominated corporation.

Name *

Name

Phone *

- -
### ### ####

Relationship *

Email *

Name

Phone

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### ### ####

Relationship

Email

Upon signature, the nominator is certifying that all information given on this form is true and accurate to the best of his/her knowledge.

Full Name *

Today's Date

* I certify that all information given is true and accurate to the best of my knowledge.

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Nominator

Nominee

Why?

Comments

References

Certification

Complete