USQRA Hall of Fame Nomination Ballot

Print for best results

UNITED STATES QUAD RUGBY ASSOCIATION
HALL OF FAME NOMINATION FORM

Nominee's Name: _________________________________________Date:__________

Address:_________________________________________________________________

City: ____________________________ State __________ Zip_____________________

Age:____________________Phone:___________________________________________

Disability:______________________________Occupation:____________________

PERSONAL INFORMATION OF NOMINEE; (Education, Service Record, Marital Status, Etc.)

________________________________________________________________________

SPORTS PARTICIPATION AWARDS;

Regional:__________________________________________________________________

National:__________________________________________________________________

International:________________________________________________________________
(Where additional sheets required please state "see attached")

Name of person submitting nomination: _______________________________________

Address:___________________________________________________________________

City: _______________________________ State __________ Zip_____________________

Team Affiliation:_________________________________________________________

Your Signature: ____________________________________Date__________________

Mail completed ballot to: Brad Mikkelsen - 1605 Mathews Street - Ft. Collins CO 80525

Related Pages: Letter of Introduction - Hall of Fame Criteria for Selection

How to Contact us | Quad Rugby Central Index