test

AddressCityState/ProvincePostal CodeContact NameTitlePhone NumberEmail

NOMINEE INFORMATION

Name of Unit/CompanyAddressCityState/ProvincePostal CodeContact NameTitlePhone NumberEmail

NOMINATED FOR THE FOLLOWING AWARD

(check one)Mark of Excellence Award
Community Awareness Award
5-Year Service Award
10-Year Service Award
15-Year Service Award
20-Year Service Award
International Awareness Award

THIS UNIT/COMPANY IS BEING NOMINATED FOR THIS AWARD BECAUSE...

THIS UNIT/COMPANY HAS DEMONSTRATED A COMMITMENT TO IMPROVING NIGHT VISION SAFETY IN THE INDUSTRY BY...

I HAVE KNOWN/WORKED WITH THIS UNIT/COMPANY FOR

YRS.MOS.

THIS UNIT/COMPANY HAS OPERATED/UTILIZED NIGHT VISION

YRS.MOS.