2019 EPIC Nomination
RequiredRequired Question(s)
Exceptional People Impacting the Community
Nomination Deadline is Friday, March 1, 2019
 
Required 1.

Nominee's Name

 

50 characters left.
2.

Nominee's Company/Organization

 

50 characters left.
Required 3.

Nominee's Phone Number

 

50 characters left.
4.

Nominee's Fax Number

 

50 characters left.
Required 5.
Nominee's Email Address
 

50 characters left.
6.
Nominee's Street Address 
 

50 characters left.
7.

Nominee's Address-City State Zip

 

50 characters left.
Required 8.
Please check the category(s) that the nominee represents:
(EPIC committee determines final categories)
Advocate
Community Service/Government
Education
Philanthropist
Media/Celebrity
Medical
Mental Health Consumer
Public Official
Other  
Required 9.
Please describe why you are nominating this individual for an EPIC Award.  
You must also include the name, telephone and fax number, address 
and role in the community of two (2) additional people supporting this nomination. 
 

1000 characters left.
10.

Additional space for nomination narrative (if needed)

 

1000 characters left.
Required 11.
Is the person being nominated aware of your nomination?
Yes
No
  • Comment:

  • 500 characters left.
Required 12.
If chosen, could nominee attend the EPIC Awards on Wednesday May 8, 2019?
Yes
No
  • Comment:

  • 500 characters left.
Required 13.
Nominator's Contact Information

First Name:
Last Name:
Company Name:
Work Phone:
Email Address:
emailaddress@xyz.com
Address 1:
Address 2:
City:
State/Province
(US/Canada):
Postal Code:

You must also include the name, telephone and fax number, address and role in the community of two (2) additional people supporting this nomination.
 
Required 14.

Name, Address, Telephone, Fax & Role in the Community
of 
an additional person supporting this nomination (1)

 

350 characters left.
Required 15.
Name, Address, Telephone, Fax & Role in the Community
of an additional person supporting this nomination (2)

 

350 characters left.