Nominee's Information
Name:  

Age:  

Mailing address:  

Mailing address line 2:

City:  

State:  
ZIP:  
Phone number (day):  

Phone number (night):
Your Information
Name:  

Email address:  

Mailing address:  

Mailing address line 2:

City:  

State:  
Zip:  
Phone number (day):  

Phone number (night):

Why do you feel that your nominee should be chosen for the Gallery of Hope?  
How did you find out about the Gallery of Hope?