Legacy Nomination Form

Please complete this form to submit how the nominee exhibits traits in all areas of consideration.

To download a PDF of the nomination form, Click Here.

NOMINATION DEADLINE: WEDNESDAY, JANUARY 10, 2018.

Your Information

Nominee's Information

Awards

Please mark the award for which you are submitting a nomination.

Eligibility Criteria:

  • Outstanding financial donations to not-for-profit organizations devoted to educational, cultural, social or public health concerns
  • Generous volunteering of time and talent to benefit a segment of our community
  • Philanthropic work motivated by selfless love of humankind

Eligibility Criteria:

  • Demonstrated leadership through community service including civic, cultural, economic, charitable, recreational or educational
  • Nominee demonstrates one or more of the following attributes: Vision, courage, initiative, motivation, selflessness, commitment, dependability, accomplishment

Eligibility Criteria:

  • Individual physician or medical practice that demonstrates selfless dedication to the community through philanthropy or service to improve the health of individuals or access to health care

A COPY OF THE OFFICIAL REGISTRATION #CH119 AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE CONSUMER SERVICES BY
CALLING TOLL-FREE 1-800-435-7352 WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL, OR RECOMMENDATION BY THE STATE.
THIS ORGANIZATION RETAINS 100% OF ALL CONTRIBUTIONS RECEIVED.