Capital District LGBT Health Awards NOMINATION FORM

Name of Individual or Organization:

       _____________________________________________________

If Individual, his or her professional affiliation:

       _____________________________________________________

Briefly describe their contribution to LGBT Health in the Capital District and why you feel they should be recognized.

       _____________________________________________________

       _____________________________________________________

       _____________________________________________________

       _____________________________________________________

       _____________________________________________________

The following information is not required, but may be helpful if we have questions about the nomination you are making.

Your Name: _________________________________________

Your e-mail address: _________________________________________

Your phone number: _________________________________________

MAIL TO:
Rainbow Access Initiative, Inc.
PO Box 9144
Niskayuna, NY 12309