NOMINATION ACCEPTANCE FORM

(*) Indicates Required Field

(ALL FIELDS ARE MANDATORY)

Nominated By(*)
Please type your full name.

Title(*)
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The Title of the Person you are Nominating

First Name(*)
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Last Name(*)
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Type of Industry(*)
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Number of Years(*)
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Type of Martial Art or Type of other Warrior Position(*)
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Rank(*)
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Date of Birth(*)
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Address (Street Number)(*)
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City(*)
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State(*)
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Zip(*)
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Home Phone(*)
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Mobile(*)
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E-mail(*)
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Award Selection(*)
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Will You Be Attending Alone(*)
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MEAL(*)
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Are You Part of a Group?(*)
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Group Name(*)
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**Note: Each Attendee must Submit an Individual Registration Form

Inductee Registration Fee:

$159

Total:
USD $0.00

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