nominATION FORM

Your Name *
Your Name
Your Address *
Your Address
Your Phone
Your Phone
Nominee Name *
Nominee Name
Nominee Address *
Nominee Address
Nominee Phone *
Nominee Phone
Confirmation of Class Action *
Did this case close/settle prior to 02.28.15? *
The date will help us place your nominee in the correct category.
How would you describe the case? *
Summarize for us what we need to know about the heroism and sacrifice of your nominee in 150 words or less.