NAME OF NOMINEE:______________________________________________________________________

ADDRESS:_______________________________________________________________________________

CITY:______________________________, GA ZIP:___________

COUNTY:__________________________ PHONE:(____)_________________

NAME OF NOMINATOR:__________________________________________

ADDRESS:______________________________________________________

CITY:______________________________, GA ZIP:___________PHONE: (____)__________________

REFERENCES FOR VERIFICATION:

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WHAT MAKES THIS PERSON THE BEST CASE MANAGER IN OUR STATE? ( use a separate sheet of paper if you need more room.)

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IS THE NOMINEE A MEMBER OF ANY CIVIC ORGANIZATIONS OR CLUBS?

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The Nominee must be a member in good standing with AFPAG. All Applications must be Postmarked no later than December 31, 2004. Winners will be selected by a Committee appointed by the AFPAG Executive Board. Winner must attend the Awards Banquet at our annual conference.