EmailMe Form - NOMINATION FORM

Check application before submitting

You may make changes and return to the application anytime before you click the submit button. Once you hit the submit button, you will be unable to make any changes. For information or questions,contact Jim Faircloth, Executive Director at 775.772.8721 or email: director@cabletvpioneers.com

Information provided will be used in producing PR and promotional materials.

Part A. Candidate Information

Contact information will only be used for Cable TV Pioneer communications.

Select One *

Actively Working

Retired

Deceased

Candidate Name *

First Last

Candidate's Spouse/Partner

First Last

Business Name

Business Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Business Phone

### - ### - #### Ext. ###

Home Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Select One: *

Send mail to home address

Send mail to business address

Cell Phone

### - ### - ####

Email *

Alternate Email

Upload a Photograph of the Candidate

High Resolution Color Photo Preferred. Accepted formats: JPG, PNG, TIF (or ZIP Archive of these formats)

1 / 4