SCHEART Quarterly Award
Nomination Form

* indicates required fields

Ham Nominee (please enter information about nominee)
* Nominee's Name:
Call Sign:
License Class:
Address:
Phone Number:
E-mail:
Nomination Quarter:	1st 2nd 3rd 4th
Support Agency:
Support Agency Contact Name:
Support Agency Contact Phone Number:
Position/Job Title:
Number of years as a Ham:
Please provide specific bullets on how the Ham you are nominating made significant contributions to your agency, region, or program:

Additional Information:

Give one specific example of what makes this person stand out and why they're deserving of recognition.

Nominated by (please enter your information):
Your name:
Relationship to Nominee:
Address:
Phone Number:
* Email:

Columbia, SC 29208 • 803-978-7576 • gipsond@mailbox.sc.edu