'Twenty under 40!' 2019 Nomination Form

1. Your Name (Required)
2. Your Occupation/Company (Required)
3. Your Address (Required)
4. Email (Required)
5. Your Preferred Phone Number (Required)
6. Your Cell Phone number (if different than preferred)

1. Nominee Name (Required)
2. Age (Required)
3. Gender (Required)
4. Address (Required)
5. Phone Number (Required)
6. Nominee Email (Required)

You must also include a summary addressing the following clearly and thoughtfully. The selection process will be based
solely on the information provided. Please be as accurate and detailed as possible

1. Reasons for Nominating (include what distinguishes this person over other applicants) (Required)
2. Professional and personal achievements (including awards, career advancements, certifications and memberships) (Required)
3. Community Involvement (Required)
4. Education (high school and/or college and degree received) (Required)

By submitting this application you agree that, in partial consideration for the above noted nominee to be considered for the recognition, you hereby waive any and all claims against the Canton Regional Chamber of Commerce, ystark!, all sponsors and supporters of the event, including without limitation all members of the event committee, arising from or connected with your submission of this nomination form and the selection of the recognition recipients.