Survey must be completed by ACS Staff and/or an Event Leadership Team Member and/or Area/Region Leadership Team Member and/or Current/Alumni VOH
Contact Information
First Name:
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Last Name:
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Email:
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Phone:
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Nomination submitted by:
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ACS Staff
Leadership Team Member
About the Nominee
Nominee Name:
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Phone Number:
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Email:
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City:
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State:
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State
AK - Alaska
AL - Alabama
AR - Arkansas
AZ - Arizona
CA - California
CO - Colorado
CT - Connecticut
DC - District of Columbia
DE- Delaware
FL - Florida
GA - Georgia
HI - Hawaii
IA - Iowa
ID - Idaho
IL - Illinois
IN - Indiana
KS - Kansas
KY - Kentucky
LA - Louisiana
MA - Massachusetts
MD - Maryland
ME - Maine
MI - Michigan
MN - Minnesota
MO - Missouri
MS - Mississippi
MT - Montana
NC - North Carolina
ND - North Dakota
NE - Nebraska
NH - New Hampshire
NJ - New Jersey
NM - New Mexico
NV - Nevada
NY - New York
OH - Ohio
OK - Oklahoma
OR - Oregon
PA - Pennsylvania
RI - Rhode Island
SC - South Carolina
SD - South Dakota
TN - Tennessee
TX - Texas
UT - Utah
VA - Virginia
VT - Vermont
WA - Washington
WI - Wisconsin
WV - West Virginia
WY - Wyoming
AS - American Samoa
FM - Federated States of Micronesia
GU - Guam
MH - Marshall Islands
MP - Northern Mariana Islands
PR - Puerto Rico
PW - Palau
VI - Virgin Islands
AA - Armed Forces Americas
AE - Armed Forces
AE - Armed Forces Pacific
Zip Code:
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Is this nominee a:
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Cancer Survivor
Caregiver
Both a Survivor and Caregiver
ACS Event Association:
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How do you know this nominee?
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How long have you known this nominee?
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Have you heard this nominee speak?
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What is one additional thing you would like us to know about this nominee?
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