Years of Service Award Nomination Form

CLINIC will recognize the commitment and dedication of affiliate staff members who have served in your organization for exactly 5, 10, 15, 20, 25, or 30 years.

The submission period will end on Monday, April 27.  We will notify nominees between April 28 - May1.

Please complete a separate form for each individual from your agency.

Please attach a photo of the nominee - To be used during the awards lunch
One file only.
256 MB limit.
Allowed types: gif jpg png.