2018 VANA Industry Awards Night - Lottery Agent of the Year - Agent Self Nomination

NOMINATION FORM - LOTTERY

Question Title

* 1.
Nominee / Nominator Details

Name

Newsagency Name

Address

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 2.
DECLARATION

I warrant that the information submitted in this entry is true and correct.

Date / Time

Date

Question Title

* 3. Signed By