Nomination Form

Thank you for caring enough to nominate an exceptional fundraiser for LLS!

Candidates should be dynamic individuals who are well-connected in their communities and will be relentless in their efforts to raise funds to find cures for blood cancers. Once selected, candidates will participate in a ten-week fundraising campaign in support of lifesaving therapies and treatments for blood cancer patients.

Please complete the form below to nominate your extraordinary individual. Once your nomination is submitted, someone from your region will contact you to discuss it further

Nominee Information

Candidate First Name *

Candidate Last Name *

Why are you nominating this person? *

If other was selected, please explain:

Zip/Postal Code *

Phone Number: (123) 123-4567 *

Phone Type: *

Home

Work

Cell

Email Address: *

Email Type: *

Personal

Work

Company/Business Name: *

Job Title: *

Your Information

First Name: *

Last Name: *

Phone Number: (123) 123-4567 *

Phone Type: *

Home

Work

Cell

Email Address: *

Email Type: *

Personal

Work

Comments: *